Conceiving and giving birth is a significant and special event that many women cherish and regard as a happy and enriching experience^1,2; however, for some women, it can lead to psychological distress, which can trigger mental health disorders, including postpartum stress disorder.^1,2 An increasing body of evidence suggests that the experience of childbirth may be linked to the development of postpartum post-traumatic stress disorder (PTSD) and that it is more common than previously believed.^3,4 Early research on PTSD was mainly associated with military veterans; it is only in recent years that PTSD following childbirth is being recognised and investigated.⁵ There has been debate as to whether childbirth should be regarded as a traumatic event, as it is not sudden or unexpected and voluntary.^6,7 Post-traumatic stress disorder is classified as a trauma and stressor-related disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5.⁸ It is characterised by symptom clusters such as re-experiencing, avoidance, negative cognitions and mood, as well as hyperarousal, following exposure to a traumatic event.⁸ A traumatic event involves personally experiencing or being exposed to actual or threatened death or serious injury to oneself or others. Studies have shown that the childbirth experience can result in the woman perceiving that her life or that of her child is in danger, thereby fulfilling this criterion.^4,9 Research on postpartum mental health has largely focused on postpartum depression, and while many are familiar with postpartum depression and psychosis, there is a dearth of literature on the phenomenon of postpartum PTSD, particularly in Africa.^6,10 A systematic review investigating psychological disorders in the pre- and postnatal period among women in Africa found that depression was the most commonly assessed disorder.¹¹ The consequences of postpartum PTSD are varied, warrant attention and may be considered a public health concern as it may adversely affect mother–child bonding and impair foetal growth and cognitive development, as well as marital difficulties.^12,13 The first descriptions of traumatic experiences associated with childbirth were documented in case study.¹⁴ These authors documented women who experienced intrusive symptoms such as nightmares about giving birth, sometimes even years after the births.^1,14 Over time, qualitative and quantitative studies reported women developing PTSD symptoms after childbirth, even after successful health outcomes.^10,14 In 2000s, further research suggested that PTSD can occur as a result of childbirth after controlling for pre-existing psychiatric conditions before childbirth.^3,4 Postpartum PTSD can be conceptualised in two ways. Firstly, it can occur as a result of the childbirth experience that triggers pre-existing PTSD. Secondly, it can indicate new-onset PTSD that is induced by childbirth itself.¹² A stress-diathesis approach has been used to identify factors giving rise to postpartum PTSD; it is described as an interplay between pre-birth vulnerability factors, risk factors in birth and factors after birth.¹⁵ Factors that have been identified in the predictive model for women with traumatic childbirth at risk of developing postpartum PTSD include low social support and poor coping.¹⁶ There are variable estimates of the prevalence of postpartum PTSD, with more recent studies indicating rates ranging between 3.4% and 11%.¹⁴ The differences in rates may be attributable to several factors, including differences in the time of measurement of PTSD symptoms, different screening tools for PTSD, sample sizes and methodological approaches.^5,17 The majority of studies were undertaken in Western and Middle Eastern countries.^6,7,18 A systematic review reported a prevalence of 4.9% in women who did not have a history of pre-existing PTSD before childbirth. This systemic review of 36 articles included studies with high methodological ranking and controlled for PTSD symptoms before childbirth.¹² The dearth of studies on postpartum PTSD in Africa is a matter of concern, particularly considering the potential implications for maternal health and well-being. Against this backdrop, a cross-sectional survey was conducted in Nigeria to determine the prevalence of postpartum PTSD.¹⁹ The survey involved a cohort of 876 women who were 6 weeks postpartum and were examined to determine the presence of postpartum PTSD. The study estimated a prevalence of 5.9% for postpartum PTSD, which suggests a significant incidence of this disorder among postpartum women in Nigeria.¹⁹ In 2024, a community based cross-sectional study conducted in south west Ethiopia found a 21.6% prevalence rate of postpartum PTSD from 624 participants. The identified risk factors included postpartum intimate partner violence, caesarean section delivery, instrumental delivery and maternal morbidity.²⁰ Despite this, no study has been found that investigates the prevalence of PTSD in relation to childbirth in South Africa. This gap in the literature highlights the need for further research to be conducted in this area; hence, the current study aimed to investigate the occurrence of PTSD symptoms among women in Johannesburg metropolitan clinics at 6 weeks postpartum. The present study aims to build upon previous research in the field and provide a better understanding of the prevalence of postpartum PTSD in African contexts. Such research can help in the development of evidence-based interventions to improve the quality of care provided to women during childbirth.

The study examined the occurrence of PTSD in a cohort of women 6 weeks postpartum. The results showed that 1.1% of women fulfilled the criteria for PTSD according to the CBTS at 6 weeks postpartum. In addition, a large portion of women (48.9%) perceived their most recent childbirth to be a psychologically traumatic event. This is similar to work done in Australia which found 45.5% of women are likely to report childbirth as being a traumatic experience.⁴ The results of the study have highlighted that women who did not perceive the experience of childbirth as a traumatic event subsequently experienced symptoms of post-traumatic stress, such as intrusion and avoidance. This may be attributed to a number of factors, including the potential challenge of comprehending the screening tool’s questions. Additionally, it could suggest that women may be hesitant to express negative emotions surrounding childbirth, which is often regarded as a joyous occasion by society. However, it may also be interpreted as an appropriate response to a significant life event like childbirth.²² The PTSD prevalence found in this study is lower than a prevalence rate of 4.9% reported in a meta-analysis in 2017; however, previous studies have reported similar rates.²² In the same vein, our rate is also notably lower compared to a similar study done in Nigeria, which estimated a prevalence rate of 5.9%.¹⁹ Although both studies examine postpartum PTSD in non-western settings at 6 weeks postpartum, there are several factors that may contribute to the differences in prevalence rates; these include differences in sample size and the different measures used. The study conducted in Nigeria used a clinically structured interview and psychiatric interview to diagnose PTSD and had a much larger sample. The present study used the CBTS, which is a recent measure based on DSM 5 criteria for PTSD, while the study in Nigeria used the Mini International neuropsychiatric interview for psychiatric disorders in DSM 4. The current study was unable to identify associated factors reliably; however, there may be differences between the two countries with regard to access to obstetric care and practices. Other factors may be differences in exposure to trauma in either country or different cultural contexts.²³ Both studies did not control for pre-existing maternal PTSD; therefore, they are unable to identify if the PTSD symptoms endorsed are a result of childbirth alone being the precipitating traumatic event. Good social support is a protective factor against the development of PTSD.²⁴ In most cultural settings, there are postpartum practices in which experienced women stay with a new mother for a prescribed period of time, helping her adjust to her new role; this may confer coping skills and hence contribute to the low PTSD prevalence found in the current study.²⁵ Evidence indicates that the expression of PTSD symptoms may vary due to differences in culture and that idioms of distress may influence the clinical presentation.⁸ Most studies investigating postpartum PTSD have been in Western countries. There is a need for the use of culturally appropriate measures to be used in further studies in our setting. There may have been an under or over-detection of PTSD as the measure used in this study has not been validated and may not be culturally appropriate. Our study observed a correlation between re-experiencing and avoidance symptoms, which is similar to other studies and consistent with the two-actor solution of re-experience or avoidance.²⁶ The present study indicates that women who perceive childbirth as traumatic are more likely to go on to develop intrusion and avoidance symptoms. This highlights the need for further research in this field so as to offer targeted interventions.

The percentage of participants who met full diagnostic criteria for PTSD at 6 weeks postpartum was lower than expected compared to international research. However, the percentage of participants who perceived birth as a traumatic experience was in keeping with findings from international literature. This suggests the need for further research in the longer-term follow-up of women reporting birth as a traumatic experience but not experiencing full diagnostic PTSD symptoms at 6 weeks postpartum. There is a gap in knowledge on childbirth-induced PTSD and postpartum PTSD in South Africa and Africa generally. The current study has been beneficial in providing information on an under-investigated topic. Further study in this area is needed to assist in developing targeted policies and screening tools.