Many new mothers struggle with birth-related trauma symptoms even without meeting criteria for PTSD

A survey of more than 11,000 new mothers across 31 countries indicates that nearly one in four women perceive their childbirth as traumatic, and roughly 7% in the surveyed nations develop childbirth-related post-traumatic stress disorder (PTSD). The findings, published in The British Journal of Psychiatry, also suggest that birth trauma rates vary widely across nations and that many more women experience distressing trauma symptoms without meeting criteria for a formal diagnosis. Together, the results point to a widespread mental health burden after delivery and highlight the need for trauma-informed maternity care that routinely screens for and responds to birth-related trauma.

Around 140 million births occur worldwide each year. Although having a baby is often viewed positively, labor, delivery, and the immediate postpartum period can sometimes involve medical emergencies for the mother or infant, or mistreatment such as coercion by healthcare staff. What counts as a traumatic birth has been defined in various ways across prior research, but in this study a birth was counted as traumatic when the person giving birth believed that she or her baby faced serious injury or death.

Some women who experience a traumatic delivery develop childbirth-related PTSD (CB-PTSD). Under the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), this condition involves four symptom categories lasting at least a month: reliving the birth through intrusive memories, flashbacks, or nightmares; avoiding reminders of the event; negative shifts in mood and thinking; and feeling constantly tense or easily startled, known as hyperarousal. Childbirth-related PTSD is linked to postpartum depression, fear of future births, reduced breastfeeding, relationship strain, and potential difficulties with mother-infant bonding.

Early efforts to gauge how often the condition occurs pooled separate local studies. For instance, a 2017 meta-analysis by two of the same authors examined 59 studies and estimated that 4.0% of women in community samples developed postpartum PTSD, rising to 18.5% in high-risk groups. Broadening that picture, a 2022 meta-analysis that included study co-author Maria Kazmierczak analyzed 154 studies and found that 4.7% of mothers met full criteria for birth-related PTSD, while 12.3% had substantial symptoms below the diagnostic threshold.

Even a lower estimate of 3% prevalence means that over 4 million women develop childbirth-related PTSD annually. However, most prior research came from high-income Western countries, alongside a smaller set of Middle Eastern studies that reported higher rates, which the authors suggest may reflect more limited maternity care, socioeconomic challenges, and health inequalities. Because separate studies used different measurement tools, study designs, and diagnostic cutoffs, researchers lacked a uniform way to compare countries directly.

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A step toward uniform measurement came when a 2018 study by two of the same authors developed the City Birth Trauma Scale in a sample of 950 postpartum women, establishing a 29-question survey that evaluates childbirth-related PTSD under DSM-5 criteria. Building on that tool, lead author Susan Ayers and study co-author Rebecca Webb, a research fellow, both at the Centre for Maternal and Child Health Research at City St George’s, University of London, teamed up with colleagues around the world. They worked with an international team of researchers to launch the International Survey of Childbirth-Related Trauma (INTERSECT) and estimate the prevalence of traumatic birth and childbirth-related PTSD using standardized methods across countries.

“Previous research showed that between 20-40% of women find their birth to be psychologically traumatic, and approximately 3-4% of women will develop childbirth-related PTSD as a result,” Webb told PsyPost. “However, a lot of this research was carried out in higher-income countries, using different measures to assess childbirth-related PTSD and birth trauma. This means that cross-country and cross-study comparison of rates, symptoms, and risk factors for birth trauma and childbirth-related PTSD is difficult. Therefore, the INTERSECT study aimed to look at prevalence, symptoms and risk factors for birth trauma and childbirth-related PTSD across the world, using consistent measures of childbirth-PTSD.”

The researchers conducted a cross-sectional survey between April 2021 and January 2024 across 31 countries: Australia, Brazil, Chile, Croatia, Cyprus, Czechia, Estonia, Germany, Iceland, Ireland, Israel, Italy, Lithuania, Malawi, Nepal, Nigeria, Norway, Pakistan, Poland, Portugal, Romania, Saudi Arabia, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, the United Arab Emirates, and the United Kingdom. The protocol was preregistered, and the anonymized dataset is available to researchers on application through the UK Data Service. Adult women were eligible if they were 6 to 12 weeks postpartum (averaging 8.5 weeks). After excluding 1,025 responses completed outside that window, the final sample comprised 11,302 women, with country samples ranging from 127 in Chile to 1,644 in Germany.

Participants were recruited through routine maternity services, plus social media in Norway and Slovenia, completing the survey on paper or online in 29 countries and by phone in Brazil and Germany. Overall, 3,355 participants came from seven low- or middle-income countries (Brazil, Malawi, Nepal, Nigeria, Pakistan, Serbia, and Turkey). The most common age group was 30 to 34 years (33.6%), and most respondents were married (67.6%), higher-educated (57.3%), and earning an average household income (58.5%), while 9.7% identified as ethnic or racial minorities.

Obstetric histories also varied across the participating countries. Across the full sample, 51.3% of participants were first-time mothers, 64.3% had a vaginal birth, 6.2% had an instrumental vaginal delivery, and 29.5% had a cesarean delivery. Overall, 7.8% of mothers reported major medical complications for themselves and 4.4% reported major complications for their infants.

Outcomes were assessed with the 29-item City Birth Trauma Scale in English or local translations. A birth was coded as traumatic if a participant answered “yes” to believing that she or her baby would be seriously injured or die during labor, birth, or immediately afterward. Childbirth-related PTSD required a traumatic birth plus at least one re-experiencing symptom, one avoidance symptom, two negative mood or cognition symptoms, and two hyperarousal symptoms in the past week, lasting at least one month and causing distress and impairment.

The team also assessed a dissociative subtype, coded when women with childbirth-related PTSD felt detached, dreamlike, or as if their surroundings were unreal, and acute childbirth-related PTSD, when all criteria were met except the one-month duration. While acute childbirth-related PTSD is not a formal diagnostic category, the authors note it may indicate delayed-onset PTSD. Additionally, participants indicated whether symptoms might stem from medication, alcohol, drugs, or physical illness to test for alternative medical explanations, called differential diagnoses. Country prevalence estimates were calculated using multilevel logistic regression, which draws on the full sample to improve the accuracy of country-level estimates.

Across the 31 participating countries, which were mostly high-income European nations, the estimated prevalence of traumatic birth averaged 23.3% (95% confidence interval: 22.4% to 24.0%), with half of the countries falling between 14% and 27%. Rates ranged from 7% in the United Arab Emirates to 69% in Malawi, with high rates also recorded in Chile (49%), Nepal (41%), Saudi Arabia (40%), Spain (35%), and Turkey (35%). The prevalence of childbirth-related PTSD across the surveyed countries averaged 6.7% (95% confidence interval: 3.7% to 9.7%), with the middle half of countries falling between 3% and 7%. The authors note that this range is broadly consistent with earlier meta-analytic estimates of 3.1% to 4.7%.

Childbirth-related PTSD rates varied from 1% in Israel and 2% in several European countries, Nigeria, and the United Arab Emirates up to 36% in Malawi and 33% in Saudi Arabia, followed by Turkey (14%), Estonia (10%), Pakistan (10%), and Nepal (9%). Experiencing a traumatic birth did not translate into full PTSD at the same rate everywhere. In Saudi Arabia, 83 of the 97 respondents reporting a traumatic birth (86%) met full criteria for childbirth-related PTSD, compared with 53% in Malawi, 22% in Nepal, and 17% in Chile.

Many more women reported that trauma symptoms caused emotional distress or disrupted daily life than met diagnostic criteria. Across countries, an average of 44.5% of women (from 5% in Israel to 82% in Pakistan) reported distress, and 34.1% (from 4% in Nigeria to 80% in Pakistan) reported impairment. The authors suggest that earlier reviews estimating subthreshold symptoms at 12.3% likely underestimated non-diagnostic symptom rates due to measurement differences.

The dissociative subtype averaged 3.8% across countries (ranging from 1% to 24%) and was over half the size of the PTSD rate in many countries, suggesting dissociative symptoms are common among women with the condition. Malawi was a notable exception, at 1% despite a 36% PTSD rate. Acute childbirth-related PTSD averaged 1.3% (0% to 7%) and stayed near zero in most countries aside from Nepal (7%) and Turkey (6%).

Excluding possible differential diagnoses from physical illness, medication, or substances left prevalence rates largely unchanged in most countries, which the authors say supports the validity of earlier studies that did not account for those medical factors. However, removing those cases reduced estimated childbirth-related PTSD rates in Pakistan (from 10% to 2%), Nepal (from 9% to 4%), Saudi Arabia (from 33% to 29%), and Turkey (from 14% to 12%).

The authors suggest that the wide variation across countries may reflect unique cultural, sociodemographic, and healthcare factors, as well as varying maternity ward restrictions during the COVID-19 pandemic. At the same time, they note that methodological differences across sites, such as how women were recruited and how surveys were administered, may also have contributed to cross-country differences. Regarding the drop in prevalence in a few countries when excluding physical illness or medication effects, the researchers propose that higher exposure to physical health complications or cultural differences in stigma and disclosure could play a role.

Beyond formal diagnostic thresholds, the findings point to a broad burden of postpartum distress. “Many women experienced significant distress and impairment even when they did not qualify for a formal CB-PTSD diagnosis,” Webb noted.

In a companion study on cross-national risk factors using the same international dataset, the team also examined which experiences were most strongly associated with the disorder. “Across countries, the strongest predictor of CB-PTSD was having a negative birth experience, followed by ongoing maternal health complications, and major infant complications, suggesting that both emotional and physical care are key in preventing CB-PTSD,” Webb explained.

A separate companion analysis of symptom presentation explored how those trauma responses manifest across different countries. “In terms of symptom presentation, the severity of CB-PTSD symptoms differs between countries, but the way the symptoms show up is similar across the countries included in this research,” Webb said. “Avoidance symptoms (e.g. avoiding things that remind women of the birth) were the best at predicting whether someone had CB-PTSD or not.”

There are a few things to keep in mind when interpreting these results. Because women were recruited from specific maternity clinics rather than national registries, and response rates were not tracked across all sites, the country samples are not necessarily nationally representative and may reflect selection bias. The authors also point out that wide confidence intervals for several estimates indicate statistical uncertainty, and differences in survey administration formats alongside pandemic-era hospital restrictions complicate cross-country comparisons.

In addition, the study relied on self-reported questionnaires rather than clinical diagnostic interviews, which remain the gold standard for psychiatric diagnosis. As a result, the prevalence figures reflect women whose questionnaire responses met DSM-5 criteria rather than women formally diagnosed by a clinician, and the survey did not assess other psychiatric disorders as potential overlapping diagnoses. Participants from low- and middle-income countries made up just under one-third of the sample, leaving lower-resource regions underrepresented in the overall averages, and the researchers note that questionnaires developed in English may be less suited to capturing culturally specific expressions of trauma in non-Western settings.

Future research would benefit from national sampling frames, clinical interviews, and targeted follow-up in countries with unusually high or low trauma rates to better understand contextual and methodological influences and identify protective healthcare practices. Because so many mothers experienced distress and daily impairment without meeting full diagnostic criteria, the authors emphasize that routine perinatal mental healthcare should include trauma-informed assessment and culturally tailored support for both diagnostic and subthreshold symptoms.

The consortium is already working to expand its network of international partners through a second wave of the survey. “Wave 2 of data collection is currently in progress, and will end at the end of the year (December 2026), and is likely to include data from 30 additional countries,” Webb said.

“We have some really interesting sub-studies and groups that have formed as part of INTERSECT, known as INTERSECTplus,” Webb added. “These include additional measures that have been added to the INTERSECT survey (e.g. measures of CB-PTSD in fathers/birth partners, or measures of maternal mistreatment), qualitative studies on sub-samples, systematic reviews, as well as the many PhD projects that are incorporated into the INTERSECT study.”

The study, “International prevalence of childbirth-related post-traumatic stress disorder: INTERSECT study,” was authored by Susan Ayers, Jonathan E. Handelzalts, Rebecca Webb, Georgina Constantinou, Christopher Grollman, Grace Lucas, Natalia Awad-Sirhan, Kathleen Baird, Marcia L. Baldisserotto, Rami Batool, Shahida Batool, Maja Brekalo, Rafael A. Caparros-Gonzalez, Genesis Chorwe-Sungani, Andri Christoforou, Soledad Coo, Raquel Costa, Pelin Dikmen-Yildiz, Barbora Ďuríčeková, Bohdana Dušová, Violeta Enea, Susan Garthus-Niegel, Hanna Grundström, Oye Gureje, Eleni Hadjigeorgiou, Silje Marie Haga, Antje Horsch, Chiara Ionio, Gabija Jarašiūnaitė-Fedosejeva, Julie Jomeen, Maria Kazmierczak, Joan Lalor, Maja Milosavljevic Markovic, Ursula Nagle, Sandra Nakić Radoš, Katri Nieminen, Bibilola Damilola Oladeji, Flávia de Lima Osório, Paulina Pawlicka, Yoav Peled, Tiago Miguel Pinto, Valentine Rattaz, Olga Riklikiene, Julia Schellong, Lara Seefeld, Valgerður L. Sigurðardóttir, Zuzana Škodová, Petra Dörr, Tjasa Stepisnik Perdih, Robert Stewart, Emma Marie Swift, Narendra Singh Thagunna, Kristiina Uriko, Zahir Vally, Milica Vezmar, Daniel B. Wright, Haya S. Zedan, and the INTERSECT Consortium.