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

doi:10.21203/rs.3.rs-4929867/v1

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Research Article

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

https://doi.org/10.21203/rs.3.rs-4929867/v1

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Background

There is no validated Ukrainian instrument for assessing childbirth-related Post-Traumatic Stress Disorder (CB-PTSD) according to DSM-5 criteria.

Objectives

Evaluate the psychometric properties of the Ukrainian version of the City Birth Trauma Scale (City BiTS) and examine its factor structure.

Method

In a cross-sectional study, 320 women completed online questionnaires, including the City BiTS, Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder (GAD-7) questionnaire, and a sociodemographic questionnaire.

Results

The prevalence of CB-PTSD in Ukraine was 6.2%. Confirmatory analyses were conducted to assess the fit of two-factor and four-factor models, as well as a bifactor model. The bifactor model was found to be the best-fitting model. The examination of the bifactor indices supported the computation of a total PTSD score as well as the use of the General Symptoms subscale, which emerged as distinct and well-defined factors. Both subscales (Birth-Related Symptoms subscale and General Symptoms subscale) and the total scale demonstrated high internal consistency (Cronbach's α = .92). Convergent and divergent validity testing indicated robust validity, particularly for General symptoms score.

Conclusions

The City BiTS emerged as a reliable and valid measure, recommended for use among Ukrainian women in the postpartum period as a screening method.

Trial registration. Clinical trial registration was completed at ClinicalTrials.gov under identifier NCT05654987 (Date: December 16, 2022)..

birth trauma

PTSD

war

Ukraine

postpartum

women

validation

EPDS

GAD-7

City BiTS

Childbirth elicits a complex array of emotions, including stress, pain, excitement, and joy in varying proportions [1]. Yet, for some women, it manifests as an overwhelmingly negative experience, provoking distressing emotions and reactions with lasting adverse effects on their lives [2]. While accidents, wars, and natural disasters are recognized traumatic stressors, research and clinical practice suggest that traumatic childbirth can also be recognized as a sudden and catastrophic event. It can induce a profound sense of loss of body integrity and pose risks to the lives of both mother and baby. Reviews and meta-analyses indicate that childbirth-related posttraumatic stress disorder (CB-PTSD) affects 4–6% of postpartum women in community samples after birth and up to 16,8% of postpartum women experiences clinically significant CB-PTSD symptoms [3; 4]. The prevalence of CB-PTSD is notably higher in high-risk samples ranging from 15 to 18% among women with a history of sexual abuse, emergency caesarean section, preterm delivery, or severe pregnancy complications [5; 6].

PTSD is defined as a condition that develops after exposure to an event in which there is a real or perceived threat of death or physical harm to oneself or others, as outlined in DSM-5-TR’s [7] and ICD 11’s [8] A criterion. The other symptoms, as outlined by DSM-5-TR [7], are organized into four clusters, including B - intrusion or re-experiencing the traumatic event; C - avoidance of anything related to the traumatic event; D - negative alterations in cognitions and mood; and E - arousal and reactivity. According to DSM-5-TR criteria and empirical studies, PTSD symptoms typically manifest within six months of a stressful event or the cessation of its impact [9]. However, delayed expression is common, with symptoms appearing after six months post-trauma [7].

The previuos exposure to traumatic experiences constitutes a greater risk of PTSD [10]. We assume that, as with the Ukrainian-Russian war, which began in 2014, with a full-scale invasion in 2022, the proportion of women with CB-PTSD may be higher than in non-war-affected countries. More than a third of internally displaced pregnant women who lived in the war zone in eastern Ukraine after 2014, were diagnosed with PTSD [11]. Exposure to armed conflict, changes in everyday life, previous traumatic experiences and lack of support associated with war constitute risk factors for CB-PTSD [5; 12]. Although Kurapov et al. [13] study showed that the level of PTSD and complex PTSD (CPTSD) is relatively low in the Ukrainian general population, the number of postpartum mothers who experienced war-related traumatic events with active PTSD during pregnancy can be significant and can predispose them to CB-PTSD - however we do not know the prevalence of CB-PTSD and needs of war-affected mothers in this region.

Although a routine inquiry about birth trauma by healthcare providers is essential for all postnatal women, this is particularly important for those who have been affected by very stressful events. Screening tools, such as “The City Birth Trauma Scale”, offer a contemporary method for assessing birth trauma based on DSM-5 criteria for clinical and as well as for research purposes [14]. The City Birth Trauma Scale (City BiTS) is the only measure of CB-PTSD that follows DSM-5 criteria. Beyond the original English validation, the City Birth Trauma Scale (City BiTS) has undergone validation and translation into Lithuanian [15], Australian [16], Swedish [17], Brazilian [18], German [19], French [20], Spanish [21], Croatian [9], Turkish [22], Chinese [23] and Hebrew [24] language. Depending on the language version, the questionnaire has been found to have 2 factors: Birth-related Symptoms (BRS) and General Symptoms (GS) (English, Brazilian, Spanish, Swedish, German, Hebrew, Chinese validations), 4 factors: Re-experiencing symptoms, Avoidance symptoms, Negative cognitions and mood, Hyperarousal (Turkish version) and bi-factor model with a global CB-PTSD factor and two specific factors of Birth-related Symptoms (BRS) and General Symptoms (GS) (Australian, Croatian, French and Lithuanian validation).

However, as far as we know, there is currently no research conducted on the psychometric properties of this instrument among Ukrainian women, which may result in undiagnosed cases. The primary objective of this study was to analyze the psychometric properties of the Ukrainian version of the City BiTS and elucidate the latent factor structure of CB-PTSD.

Specifically, we aimed to:

Examine the factor structure of Ukrainian version of City BiTS. Therefore, three models were tested: a four-factor model based on DSM – 5 PTSD symptoms: Intrusion, Avoidance, Negative Cognitions and Mood, and Hyperarousal), a two-factor model ( Avoidance and Intrusion as one factor and Cognition and Hyperarousal as another) and a bifactor model (incorporating a general factor and two specific factors).

Analyze the reliability of the City BiTS in the Ukrainian sample.

Establish convergent validity of the City BiTS via correlations with the Impact of Event Scale Revised (IES-R) and divergent validity via correlations with the Edinburgh Postnatal Depression Scale (EPDS) and the General Anxiety Disorder (GAD-7).

Design

Data comes from an observational cohort study (“Perinatal mental health for refugee women (PMH-RW) study”; Clinical Trial registration NCT04595123). This project aimed to assess the impact of the war on the mental health of pregnant and postpartum women by studying potential risk and protective factors.

Participants

Inclusion criteria for participation was: being a (i) biological mother of an infant up to 12 months of age; (ii) 18 years or older; (iii)war refugee from Ukraine (entrance to EU countries from 24 February 2022) or staying in Ukraine after/during the war.

371 women access the questionnaire, and 51 were excluded due to missing information in the City BiTS, therefore we included in the analysis 320 women. About two thirds (71.%; n = 226) of the women were living in Ukraine at the same place as before the war, 10.1% (n = 32) were internally displaced (different place within Ukranian region), 18.9% (n = 60t) moved to other/host countries. Data on region was missing for 2 participants. Participants in the sample were mostly highly educated, partnered or married, from the large cities, with good enough financial situation before the war which got worse since the beginning of the war (Table 1). Concerning obstetric factors, most women were primiparous (60.1%) with a singleton pregnancy (98.4%), but none had medical complications.

Table 1

Characteristics of the participants
Sociodemographic	N	%
Educational level
Incomplete secondary education	4	1.2
Full secondary education (High School)	46	14.4
University degree	270	84.4
Marital status
Single	6	1.9
Partnered/Married	279	87.2
Divorced/Separated	30	9.4
Widowed	4	1.2
Other	1	0.3
Place of residence
Large city	224	70.2
Small town	64	20.1
Rural area	31	9.7
Missing	1	0.3
Financial situation before war
Very good	54	16.9
Good enough	242	75.9
Not very good	18	5.6
Very bad	5	1.6
Financial situation since the beginning of the war
Much better	5	1.6
Improved	14	4.3
Unchanged	112	35.0
Somewhat worsen	135	42.2
Much worsen	54	16.9
Birth-related variables
Parity
Multiparus	127	39.9
Primiparous	191	60.1
Medical complications during pregnancy
No complications	320	100
Type of pregnancy
Singleton	314	98.4
Twin	5	1.6
Perinatal mental health	M	SD
EPDS	11.19	6.24
IES – R	22.58	16.57
GAD – 7	6.55	4.32

Instruments

Sociodemographic and Obstetric Data

Sociodemographic data were collected using the Assessment, Care, and Trust - Pregnant and New Mothers (ACT - PNM) questionnaire created for this study. The ACT - PNM includes questions about educational level, naritial status, place of residence, financial situation before the war and since the beginning of the war, medical complication during pregnancy andtype of pregnancy,

Birth-Related Posttraumatic Symptoms

The City Birth Trauma Scale (City BiTS; Ayers, 2018 14 ) comprises 29 items, with 20 items dedicated to measuring the four clusters of symptoms following the DSM-5 criteria: Re-experiencing (5 items), Avoidance (2 items), Negative Cognitions and Mood (7 items), and Hyperarousals (6 items) during the preceding week. Additional nine items evaluate various aspects such as stressor criteria (2 items - criterion A), symptom duration (1 item - criterion F), symptom onset (1 item) distress levels and disability (2 items - criterion G), dissociative symptoms (2 items), and alternative explanations (1 item - criterion H).

Response options are binary (yes/no) or four-point Likert scale ranging from 0 (not at all) to 3 (five or more times). The total score ranges from 0 to 60 points, with a higher score indicative of greater symptom severity. The scale contains two binary questions (yes/no) focusing on the stressor criteria (criterion A), specifically regarding the risk of death or serious injury to either the mother or the baby during labor, delivery, or immediately after. One anwser YES to these question is required for the diagnosis of PTSD The frequency of intrusive thoughts (criterion B), avoidance behaviors (criterion C), negative thoughts/mood (criterion D), and hyperarousal symptoms (criterion E) in the week prior to the evaluation are assessed through the remaining 20 items. CB-PTSD is considered if one symptom from B and C criterion is present and two from D and E.

The original version of the City BiTS showed excellent reliability with Cronbach's Alpha = 0.92 for the total scale [14], with exploratory factor analysis revealing two factors accounting for 56% of the variance: (i) Birth-related symptoms (predominantly consisting of items which measure intrusion, avoidance, and negative cognitions/mood related to birth; 40.8%) and (ii) General symptoms (mainly consisting of items assessing negative cognitions/mood and hyperarousal; 15.5%).

The City BiTS was translated into Ukrainian using the back-translation method [25]. Two expert translators translated the scale into Ukrainian; another translator and linguist back-translated it into English. The original and back-translated English versions exhibited concordance. A pilot sample of 3 participants assessed the comprehensibility of the Ukrainian version, resulting in no modifications to the questionnaire.

Symptoms of Post-Traumatic Stress Disorder

The Impact of Event Scale-Revised [26] is a tool used to evaluate self-reported symptoms of post-traumatic stress disorder (PTSD) experienced within the last 7 days, especially in the response sets of intrusion, avoidance, and hyperarousal, as well as total subjective stress. It comprises 22 items rated on a five-point Likert scale ranging from 0 to 4, with descriptors ranging from 'Not at all' to 'Extremely'. The total score ranges from 0 to 88, where a higher score indicates greater symptom severity. Internal consistency was high (Cronbach's α = .95). The internal consistency calculated for our sample was identical.

Symptoms of Postpartum Depression

The Edinburgh Postnatal Depression Scale (EPDS) [27] is a widely used self-assessment tool designed to measure depression in postpartum women. It consists of 10 items rated on a four-point scale from 0 to 3, with possible scores from 0 to 30 where a higher score indicates greater symptom severity. Cronbach ɑ was .87 in the original study [27]. In the current study, the Cronbach ɑ was also .87.

Symptoms of Anxiety

The General Anxiety Disorder (GAD-7) [28] is a 7-item instrument that assesses symptoms of general anxiety disorder. It screens for anxiety symptoms in the general population and according to the criteria established by the DSM-IV [29] and DSM-IV-TR [30]. Response options include four-point Likert scale that ranges from 0 to 3. The total score on the GAD-7 ranges from 0 to 21. The internal consistency of the original version of the GAD-7 was excellent (Cronbach α = .92) [28]. In the current study, the Cronbach ɑ was .87.

Procedure

The data collection method is described in detail elsewhere (omitted for blind revision). Data was collected through an online questionnaire using the Qualtrics® XM survey platform from 01 December 2022 to 1 October 2023. Invitations for participation were disseminated through various platforms, including Facebook groups, Instagram, personal contacts, and Ukrainian support centers in European countries. Participation was anonymous, and participants were required to read the informed consent before completing the questionnaires. The study information detailed the voluntary nature of participation and the possibility of leaving the study at any time. The study received ethical approval from institutions (blinded for the peer review process).

Statistical analysis

The sample size was calculated as 5 to 10 participants per item [31] suggesting that having at least 200 participants would be sufficient to conduct factor analysis, which was substantially exceeded.

To calculatestatistical analyses, we used SPSS Version 29.0. We employed descriptive statistics and frequency anayses to explore the prevalence of CB-PTSD and the criteria for PTSD. Descriptive statistics were also used to analyze individual items and subscales. The factor structure of the City BiTS was assessed using confirmatory factor analyses (CFA) with maximum likelihood estimation in AMOS© 26. Three models were examined: 1) a four-factor model comprising four correlated factors (Intrusions, Avoidance, Negative Cognitions and Mood, and Hyperarousal; 2) a two-factor model comprising two correlated factors (Birth-Related PTSD Symptoms and General PTSD Symptoms); and 3) a bifactor model comprising two uncorrelated factors (Birth-Related PTSD Symptoms and General PTSD Symptoms) and a general factor of PTSD. In the bifactor model, all items loaded on the general factor, had nonzero loadings on the domain-specific factor that they were designed to measure and zero loadings on the other factors. In all three models, modification indices were reviewed to enhance model fit. Whenever pairs of items were part of the same subscale, their measurement errors were allowed to correlate [32].

The fit of the models was assessed through the comparative fit index (CFI), the Tucker-Lewis Index (TLI), the root-mean-square error of approximation (RMSEA), and the standardized root-mean-square residual (SRMR). The cut-offs for adequate and good model fit were CFI and TLI values ≥ .90 and ≥ .95, RMSEA values ≤ .08 and ≤ .06, and SRMR values ≤ .10 and ≤ .08, respectively [33; 34]. The Akaike Information Criterion (AIC) [35] was used to compare the models. The model with the smallest AIC values was considered the best-fitting model. Factor loadings of .32 or above were considered meaningful [36].

Several bifactor model-based psychometric indexes were computed. Higher values of the explained common variance (ECV) indicate a strong general factor and suggest unidimensionality [37; 38]. The ECV for specific factors is only relative to items loading on that factor. The percentage of uncontaminated correlations (PUC) [39; 40] is another strength index. Higher values of PUC suggest that the parameter estimates in a unidimensional model are less likely to be biased. According to Rodriguez et al. [41], "when ECV is > .70 and PUC > .70 relative bias will be slight, and the common variance can be regarded as essentially unidimensional" (p. 232).

The omega reliability coefficients and the relative omega were also computed. For the general factor, the relative omega represents the percentage of the reliable variance in the multidimensional composite due to the general factor. For specific factors, this index represents the proportion of reliable variance in the subscale composite that is independent of the general factor.

The H index, a measure for evaluating how well a factor is captured by a group of items [42] was also calculated. High values (> .80) indicate a well-defined variable [41]. Additionally, the factor determinacy index was calculated, with values exceeding .90 necessary for individual assessment purposes [43].

Internal consistency was evaluated through item-total correlation, inter-subscale correlation, average inter-item correlation, McDonald's omega, and Cronbach's alpha coefficients. Good internal consistency was considered when Cronbach's alpha exceeds .70 and mean inter-item correlations are above .15 [44], with item-total correlations surpassing .30 [45].

External validation was conducted through Pearson correlations between the City BiTS and the Impact of Event Scale-Revised (IES-R), Edinburgh Postnatal Depression Scale (EPDS) and General Anxiety Disorder (GAD-7).

Descriptive statistics

Table 2 depicts the mean, standard deviation, range, skewness, and kurtosis for the 22 City BiTS items (items for criteria B-E and two questions about dissociative symptoms). The results indicated that all items demonstrated a complete range of values from 0 to 3. Three of the items exceeded the proposed cut-off of 3 for skewness (2, 7, 8) and three items exceeded the proposed cut-off of 10 for kurtosis (2, 7, 8) [46].

The item-total correlation of the items in the 'Re-experiencing' subscale ranged from r = 0.362 to 0.617, in the 'Avoidance' subscale, ranged from r = 0.429 to 0.557, in the 'Negative Cognition and Mood' subscale, from r = 0.269 and 0.756, in the 'Hyperarousal' subscale from r = 0.603 to 0.745, and in the 'Dissociative' subscale from r = 0.492 to 0.631. All item-total correlations are positive and statistically significant (p < .01; see Table 2). Only for item 8 the correlation coefficient is lower than .30.

Table 2

*Descriptive statistics of the City BiTS items and correlations with total score*
	Range	Mean	SD	Skewness	Kurtosis	% of responses with a score of 0	% of responses with a score of 3	Item-Total Score Correlation Coefficients r-Pearson
1. Recurrent unwanted memories of the birth	0–3	0.58	.92	1.42	0.84	65.3	6.6	.60^**
2. Bad dreams or nightmares about the birth	0–3	0.18	.51	3.22	11.06	86.6	0.9	.36^**
3. Flashbacks to the birth and/or reliving the experience	0–3	0.47	.82	1.64	1.62	70.6	3.4	.62^**
4. Getting upset when reminded of the birth	0–3	0.44	.83	1.82	2.26	73.4	4.4	.60^**
5. Feeling tense or anxious when reminded of the birth	0–3	0.47	.81	1.63	1.64	70.0	3.4	.62^**
6. Trying to avoid thinking about the birth	0–3	0.34	.77	2.34	4.53	80.0	4.44	.56^**
7. Trying to avoid things that remind me of the birth	0–3	0.18	.54	3.41	11.78	88.4	1.3	.44^**
8. Not able to remember details of the birth	0–3	0.19	.53	3.26	11.21	86.6	1.3	.27^**
9. Blaming myself or others for what happened during the birth	0–3	0.38	.80	2.06	3.13	78.1	4.1	.55^**
10. Feeling strong negative emotions about the birth	0–3	0.47	.85	1.76	2.02	71.6	5.0	.58^**
11. Feeling negative about myself or thinking something awful will happen	0–3	0.61	.94	1.35	0.57	65.0	6.9	.67^**
12. Lost interest in activities that were important to me	0–3	0.61	.98	1.43	0.69	66.3	9.1	.58^**
13. Feeling detached from other people	0–3	1.05	1.18	0.57	-1.26	48.8	17.8	.76^**
14. Not able to feel positive emotions	0–3	0.64	1.01	1.33	0.35	65.9	9.4	.75^**
15. Feeling irritable or aggressive	0–3	1.23	1.15	0.33	-1.35	37.5	19.4	.72^**
16. Feeling self-destructive or acting recklessly	0–3	0.48	.90	1.80	1.98	73.8	6.9	.64^**
17 Feeling tense and on edge	0–3	1.11	1.12	0.48	-1.20	41.3	16.3	.75^**
18. Feeling jumpy or easily startled	0–3	0.86	1.04	0.84	-0.64	51.2	10.3	.68^**
19. Problems concentrating	0–3	0.95	1.05	0.72	-0.79	45.9	11.6	.65^**
20 Not sleeping well because of things that are not due to the baby’s sleep pattern	0–3	0.87	1.09	0.83	-0.79	55	12.2	.60^**
21 Feeling detached or as if you are in a dream	0–3	0.64	.99	1.31	0.35	64.8	8.8	.63^**
22 Feeling things are distorted or not real	0–3	0.31	.71	2.35	4.75	80.8	2.5	.49^**
Note: ** p < .01

Table 3 depicts descriptive analysis for the City BiTS total scale and subscales, including range, mean, standard deviation, skewness, and kurtosis. None of them exceeded the cut-off of 3 for skewness and 10 for kurtosis [46].

Table 3

*Descriptive statistics of the City BiTS*
		Range	Mean	SD	Skewness	Kurtosis
Total scale		0–52	12.09	11.11	1.12	0.99
4 factor solution	Reexperiencing	0–15	2.15	3.08	1.73	2.54
	Avoidance	0–6	0.52	1.18	2.66	7.11
	Negative cognitions and mood	0–18	3.94	4.28	1.06	0.40
	Hyperarousal	0–18	5.49	5.03	0.77	-0.38
2 factor solution	Birth-related Symptoms	0–27	3.70	5.22	1.93	3.72
2 factor solution	General Symptoms	0–30	8.39	7.89	0.83	-0.29

Confirmatory Factor Analyses

The results of confirmatory factor analysis of Four Factor Correlated Model, Two Factor Correlated Model and Bifactor Model are presented in Table 4. The bifactor model was significantly better than the two-factor model, Δχ²(19) = 64.84, p < .001, as well as the four-factor model, Δχ²(16) = 181.39, p < .001.

As presented in Table 5, in the bifactor model, all items loaded significantly on the PTSD general factor, with nearly all items showing factor loadings surpassing .32. However, items 10, 14, 17, 18, 20, 21, and 22, although significant, had factor loadings below .32. As presented in Table 5, items belonging to the Birth-Related Symptoms factor did not load significantly on its specific factor, whereas items belonging to the General Symptoms factor loaded significantly both on the general and the specific factor. Items from the General Symptoms factor presented weaker factor loadings on the general factor (from .21 to .45) and stronger factor loadings on the specific factor (.43 to .72).

Table 4

*Confirmatory Factor Analysis of the City BiTS*
Model	χ²	df	RMSEA	CFI	TLI	AIC
1. Correlated four-factor model	689.17	164	.100	.845	.821	781.17
2. Correlated four-factor model (with correlated residuals)	495.68	158	.082	.901	.880	599.68
3. Correlated two-factor model	599.59	169	.089	.873	.857	681.59
4. Correlated two-factor model (with correlated residuals)	379.13	161	.065	.936	.924	477.13
5. Bifactor model	491.15	150	.084	.900	.873	611.15
6. Bifactor model (with correlated residuals)	314.29	142	.062	.949	.932	450.29
Notes: χ² test; df = degrees of freedom; CFI = Comparative Fit Index; RMSEA = Root Mean Square Error of Approximation; TLI = Tucker-Lewis Index; AIC = Akaike Information Criterion

Table 5

*Standardized Factor Loadings for the Bifactor Model of the City BiTS (n = 320)*
Items	General Factor	BRS	GS
Intrusions
3. Recurrent unwanted memories of the birth	.69	.02
4. Bad dreams or nightmares about the birth	.42	.33
5. Flashbacks to the birth and/or reliving the experience	.72	− .08
6. Getting upset when reminded of the birth	.80	− .21
7. Feeling tense or anxious when reminded of the birth	.84	− .19
Avoidance
8. Trying to avoid thinking about the birth	.74	− .25
9. Trying to avoid things that remind me of the birth	.64	.20
Negative moods and cognitions
10. Not able to remember details of the birth	.23	− .07
11. Blaming myself or others for what happened during the birth	.53	.08
12. Feeling strong negative emotions about the birth	.73	.05
13. Feeling negative about myself or thinking something awful will happen	.45		.43
14. Lost interest in activities that were important to me	.21		.61
15. Feeling detached from other people	.38		.72
16. Not able to feel positive emotions	.40		.71
Hyperarousal
17. Feeling irritable or aggressive	.31		.71
18. Feeling self-destructive or acting recklessly	.28		.62
19. Feeling tense and on edge	.33		.71
20. Feeling jumpy or easily startled	.25		.66
21. Problems concentrating	.22		.54
22. Not sleeping well not due to the baby’s sleep pattern	.27		.68
Note: BRS = Birth Related Symptoms; GS = General Symptoms

Bifactor Indices for the Bifactor Model

The ECV of the general factor was .544, which indicates that the general factor only explains 54.4% of the common variance extracted, supporting the non-unidimensionality of the scale. The OmegaH for the total score was .635 and the relative omega was .685, which indicates that 68.5% of the reliable variance in the total score can be accounted for by the general factor. The PUC was .526.

With regards to the subscales, the OmegaH index and the relative omega of the Birth-Related Symptoms subscale was zero, which indicates that none of the reliable variance in this subscale is independent of the general factor. In contrast, the General Symptoms subscale presented an OmegaH index of .739 and a relative omega of .883, which indicates that 81% of the reliable variance can be attributable to this subscale and is independent of the general factor.

The H index was .916 for the total score and .883 for the General Symptoms subscale, indicating that these factors are well-defined factors. In contrast, the H index of the Birth-Related Symptoms subscale was only .252, suggesting a weakly defined latent factor (see Table 6).

Table 6

*Bifactor Indices for the Bifactor Model*
Bifactor model	ECV	Omega/ OmegaS	OmegaH/ OmegaHS	Relative omega	Factor determinacy	H index
General Factor	.544	.927	.635	.685	.954	.916
Birth Related Symptoms	.068	.882	.000	.000	.608	.252
General Symptoms	.804	.912	.739	.810	.942	.883
Note: ECV = explained common variance; OmegaS and OmegaHS are omega indices for the subscales.

Reliability

As presented in Table 7, the Cronbach’s alpha and McDonald's Omega coefficients demonstrated exelant reliability.

Table 7

*Internal consistency of the City BiTS scale and subscales*
		Cronbach´s alpha	McDonald´s omega	Mean inter-item correlation
Total scale		.92	.92	.31
	Subscale
4 factor solution	Reexperiencing	.84	.86	.49
	Avoidance	.73	-	.61
	Negative cognitions and mood	.79	.80	.33
	Hyperarousal	.88	.88	.55
2 factor solution	Birth-related Symptoms	.88	.89	.41
	General Symptoms	.91	.92	.52

Convergent and Divergent Validity

The convergent validity of the City BiTS was tested via correlations with the IES-R. The City BiTS total scale and subscales correlated significantly with the IES-R total score (total score: r = .53; p < .001; Birth-related Symptoms score: r = .36; p < .001; General Symptoms score: r = .50; p < .001)

Divergent validity of the City BiTS we tested via correlations with depression symptoms (EPDS) and anxiety symptoms (EPDS-3A, GAD-7). The City BiTS total score correlated significantly, with a moderate effect size, with the EDPS (r = .60; p < .001) total score andGAD-7 (r = .58; p < .001). The Birth-related Symptoms score correlated significantly, with a moderate effect size, with the EDPS (r = .37; p < .001), GAD-7 (r = .31; p < .001),. The General Symptoms score correlated significantly, with a moderate effect size, with the EDPS (r = .61; p < .001) total score, GAD-7 (r = .61; p < .001)

PTSD Criteria

Responses to the City BiTS following DSM-5 criteria for PTSD are shown in Table 8. About 37% of women fulfilled criterion A of DSM-5 by indicating that they believed they or their baby would be seriously injured or even die during childbirth (or immediately afterwards). More than half of them re-experienced the birth and reported negative cognition and mood. More than 70% experienced hyperarousal and one-fifth of them reported avoidance symptoms. 16 women (6.2%) fulfilled all criteria for CB-PTSD.

Table 8

*PTSD and PTSD criteria prevalence (N = 320).*
		Frequency	Percent
PTSD	Yes	16	6.2
Criterion A Stressor Criterion	Fulfilled	118	36.9
Criterion B Re-experiencing symptoms	Fulfilled	168	52.5
Criterion C Avoidance symptoms	Fulfilled	70	21.9
Criterion D Negative cognitions and mood	Fulfilled	183	57.2
Criterion E Hyperarousal	Fulfilled	230	71.9
Criterion F Duration	Fulfilled	135	42.2
Criterion G Distress and impairment	Fulfilled	136	42.5
Criterion H Exclusion criteria	Fulfilled	12	3.8

The current study details the Ukrainian validation of the City BiTS, a measure specifically designed to assess CB-PTSD, aligning with DSM-5 criteria. Consistent with other language versions, the Ukrainian City BiTS was found to be a reliable and valid instrument.

In line with the Croatian [9], French [20], and Australian [16] adaptations of the City BiTS, the bifactor model, comprising a general factor along with two specific factors related to childbirth-related symptoms and general symptoms, demonstrated the best fit to the data .

The correlations between City BiTS and IES-R are lower than in other studies [9; 19]. The association of depression and anxiety scores with the Birth-related Symptoms subscale was lower compared to the General Symptoms subscale and the overall scale of the City BiTS, indicating divergent validity. These results are in line with other studies [24; 9; 19] and demonstrate good construct validity of the Ukranian CITY BiTS.

In our sample, 6.2% of women fulfilled DSM-5 diagnostic criteria for CB-PTSD. The CB-PTSD symptoms among Ukrainian postpartum mothers, although measured during war conditions, does not differ significantly compared to results obtained in postpartum mothers in other countries or even had lower birth PTSD prevalence. For the comparison, we have chosen the online suerveys as the anonymity offered by the online environment may increase participants’ willingness to disclose sensitive or perceived as shameful information [47]. The incidence rate in Ukrainian population is 2.5 – almost 3 times higher than in in Germany − 2.6% [19], Israel − 2.4% [24] but lower than in the UK − 7.1% [14], 11.8% [9] (online survey) and Lithuania − 8% [15].

About 37% of our respondents met criterion A by indicating that they believed they or their baby would be seriously injured or even die during childbirth (or immediately afterwards), which is however much higher than in other European countries. For example in Croatia 31.18% of online assessed mothers fulfilled Criterion A [9], in Germany (also online assessment) − 22% ;[19], in England − 20.3% [14]; Ayers et alonline survey), in Lithuania (also online assessment) − 28.6% [15]. More than half of our participants re-experienced the birth and reported negative cognition and mood. More than 70% experienced hyperarousal and one-fifth of them reported avoidance symptoms.

Strengths and Limitations

This study has several strengths. The study procedure was directed following the Standards for Educational and Psychological Testing [48]. It includes a large sample of postpartum Ukrainian women.

Regardless of these strengths, this study has some limitations. First, the data were collected during Ukrainian-Russian war, which could influence the generalizability of the results. The participants were gathered online, which limits inclusion to individuals who engage with technology and social platforms where the study was promoted. The majority of the respondents were women with higher education and a good financial situation, which may not reflect the results obtained by other social groups. Due to the technical problem, responses to items referring to participants' age were not recorded.Another limitation of our study is that we do not have data about PTSD symptoms prior to childbirth.

The Ukranian validation of the The City Birth Trauma Scale is valid and reliable method to measure birth-related PTSD in research and clinical work.

The CB-PTSD incidence rate is 6.2% and is similar to other countries, 37% of the participants fulfill the criterion A of DSM-5, indicating that they believed they or their baby would be seriously injured or even die, what is one of the highest number in Europe.

We encourage midwives and health care professionals to be aware of any related needs that may arise from the elvated CB-PTSD symptoms, such as the necessity for discussing this experience or increased anxiety related to subsequent deliveries.

Ethics approval and consent to participate:

The research was condacted in accordance with the Declaration of Helsinki The studies involving human participants were reviewed and approved by Comité de Ética de la Investigación, UNED (Madrid), the Research Ethics Committee of the Faculty of Psychology of Taras Shevchenko National University of Kyiv. The patients/participants provided their written informed consent to participate in this study.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

This paper is based upon work from the COST Action Riseup-PPD CA 18138 and was supported by COST under COST Action Riseup-PPD CA18138 www.cost.eu. However, sponsor did not have any involvement in the study design, collection, analysis and interpretation of data, writing of the report nor the decision to submit the article for publication.

Authors' contributions

Mch-D contributed to conception and design of the study, wrote and edited the first draft of the manuscript. AU contributed to conception and design of the study. HG-L organized the database. NM contribute dto the design of the study writing the draft and edited version and descriptive statistics part. LK and OM-L and AV contributed to conception and design of the study and provided the translation of the method as well to the data collection process. SNR and HM and RC contributed to the methodology and data analysis. SNR and RC and MR-M reviewed and edited the final version. All authors contributed to the article and approved the submitted version.

Acknowledgments

We would like to thank to all Ukrainian women who have participated in the study and were eager to share their experience in this extremely difficult war situation which affected their lives and their country.

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No competing interests reported.

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

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Abstract

Introduction

Methods

Design

Participants

Instruments

Sociodemographic and Obstetric Data

Birth-Related Posttraumatic Symptoms

Symptoms of Post-Traumatic Stress Disorder

Symptoms of Postpartum Depression

Symptoms of Anxiety

Procedure

Statistical analysis

Results

Descriptive statistics

Confirmatory Factor Analyses

Bifactor Indices for the Bifactor Model

Reliability

Convergent and Divergent Validity

PTSD Criteria

Discussion

Strengths and Limitations

Conclusion and Implications for Practice

Declarations

References

Additional Declarations

Status:

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