Perception of obstetric violence and risk of post-traumatic stress disorder at 6 months postpartum: an observational study

Introduction: Childbirth, traditionally viewed as a natural and positive process, can become a traumatic experience when obstetric violence or disrespectful treatment occurs. This type of experience can cause symptoms consistent with Post-Traumatic Stress Disorder negatively affecting maternal mental health, bonding with the newborn, and the development of the newborn.

Objectives: To analyze the relationship between perceptions of inadequate treatment during childbirth and the risk of postpartum Post-Traumatic Stress Disorder at 6 months in a sample of women assessed 3 months after birth.

Methods: An observational study with six-month follow-up was conducted in 341 women in Spain, initially recruited 3 months postpartum. Validated questionnaires were used: Childbirth Abuse and Respect Evaluation-Maternal Questionnaire (perceived abuse or disrespect), Perinatal Post Traumatic Stress Disorder, Family Apgar, and MOS social support survey Bivariate and multivariate analyses were performed using logistic regression.

Results: Three hundred forty-one women participated, with a mean age of 33.38 years (SD = 4.23). 10.9% of the participants were at risk of Post-Traumatic Stress Disorder. Childbirth Abuse and Respect Evaluation-Maternal Questionnaire dimensions correlated positively with the Perinatal Post Traumatic Stress Disorder, with “inappropriate treatment by professionals” being the most significant (r = 0.60; 95% CI: 0.53–0.67). A greater perception of obstetric violence (Abuse and Respect Evaluation-Maternal Questionnaire ≥ P95) significantly increased the likelihood of developing Perinatal Post Traumatic Stress Disorder (aOR: 48.38; 95%CI: 10.07–232.44). Associations with risk of developing Post-Traumatic Stress Disorder were also observed for instrumental birth (aOR: 5.29; 95% CI: 1.53–18.28) and previous cesarean section (aOR: 7.54; 95% CI: 1.10–51.79). More social support was associated with a lower risk of Post-Traumatic Stress Disorder (aOR: 0.96; 95%CI: 0.94–0.99).

Discussion and conclusion: A higher perception of obstetric violence is associated with an increased risk of developing postpartum Post-Traumatic Stress Disorder. Furthermore, invasive interventions such as instrumental births or previous cesarean sections increase psychological vulnerability. In contrast, social support acts as a protective factor. It is recommended to implement screening tools such as Abuse and Respect Evaluation-Maternal Questionnaire, reinforce training in respectful treatment, and promote humane care models to ensure the physical and emotional safety of women.

Introduction

The humanization of childbirth—through respectful care, emotional support, and effective communication—is associated with improved maternal mental health, fostering a sense of control, safety, and well-being, and reducing the risk of postpartum post-traumatic stress and depression (Leinweber and Stramrood, 2024). Conversely, depersonalized or disrespectful care increases the likelihood of traumatic perceptions of childbirth, negatively affecting women’s emotional well-being (Ramirez-Perdomo et al., 2024; Yalley et al., 2024).

These findings are highly relevant, as recent studies indicate that a significant proportion of women, up to 34%, experience it as an emotionally disturbing event, and between 4 and 16% develop Post-traumatic Stress Disorder (PTSD) within the first year after birth (Ayers et al., 2016; Yildiz et al., 2017). According to DSM-5-TR criteria, this disorder is characterized by intrusive memories, avoidance behaviors, neurovegetative hyperarousal, and alterations in cognitive status or mood. Its persistence can lead to serious consequences, such as functional difficulties, impaired mother–child bonding, and negative effects on children’s emotional and cognitive development (Garthus-Niegel et al., 2017). The 6 months after childbirth are considered particularly sensitive for identifying these symptoms, as they coincide with the end of the initial adaptation phase and allow for the observation of clinical trajectories that may become chronic (Ayers et al., 2016).

The onset of postpartum PTSD is not always directly related to clinical complications, but in many cases, appears to be more closely linked to the perception of having experienced obstetric violence and/or disrespectful treatment during childbirth (Reed et al., 2017; Martinez-Vázquez et al., 2021; Ortiz-Esquinas et al., 2025). The World Health Organization (WHO) has defined obstetric violence as the appropriation of bodies and reproductive processes by healthcare personnel, which constitutes a violation of human rights. This violence can take multiple forms. On a physical level, it includes interventions such as repeated vaginal examinations without consent, systematic episiotomies, or the use of the Kristeller maneuver (Bohren et al., 2015; WHO, n.d.). On a psychological level, it manifests itself in contemptuous expressions, threats, or blaming (Savage and Castro, 2017) as well as unjustified restrictions, a lack of clear information, or not allowing the woman to be accompanied during labor (Vedam et al., 2019).

In an environment characterized by the inequality of power and vulnerability inherent in the biomedical model, what should be a physiological process becomes an experience of loss of control over one’s own body and a source of avoidable suffering (Diaz-Tello, 2016).

Three aspects of obstetric violence have been highlighted as particularly traumatic. The first is the failure to provide informed consent for procedures such as artificial rupture of membranes or episiotomy (Bohren et al., 2015). The second is emotional neglect by staff, which may include inattention or derogatory comments when faced with expressions of pain (Vedam et al., 2019). The third is medical coercion, which involves undue pressure to accept interventions such as unjustified cesarean sections or unnecessary neonatal separations (Savage and Castro, 2017).

From a neuronal and psychological perspective, these experiences generate fragmented traumatic memories that tend to be reactivated in the presence of childbirth-related stimuli, such as hospital smells or baby sounds, perpetuating the symptomatic cycle (Fenech and Thomson, 2014). Evaluating women after childbirth facilitates the detection of persistent PTSD, as one-third of acute cases progress to chronicity if left untreated (Yildiz et al., 2017). Furthermore, this stage marks a crucial transition toward full motherhood, so the functional impact of the disorder may intensify (Garthus-Niegel et al., 2017) and allows for a more precise distinction between common depressive symptoms and traumatic symptoms (Ayers et al., 2016).

Despite the growing visibility of the problem, significant research gaps remain. Most studies address the phenomenon in the first 3 months postpartum, which may underestimate the true prevalence of PTSD. Given the adverse consequences that postpartum PTSD can have on women and their families, it is essential to understand and address its potential relationship with experiences of inadequate treatment during childbirth. Identifying associated risk factors would allow for the establishment of care lines and clinical guidelines aimed at promoting safe and respectful environments during childbirth, with a positive impact on maternal mental health in the postnatal period.

Methods

Design and participants

A cross-sectional observational study was conducted at 6 months of follow-up in a sample of women recruited at 3 months postpartum, and the results have been published (Ortiz-Esquinas et al., 2025). To gather the required information, an online questionnaire was disseminated across associations related to pregnancy, childbirth, and the postpartum period, as well as breastfeeding support groups throughout Spain. Birth took place between June 2022 and December 2023 in Spain. The research received approval from the clinical research ethics committees of several hospitals. All participants were informed in writing about the study objectives and provided written informed consent before their inclusion. Exclusion criteria included women under 18 years of age and those with language barriers, i.e., those who did not speak or understand Spanish.

To determine the sample size, the maximum modeling principle was applied, which stipulates the inclusion of at least 10 subjects for each independent variable (Peduzzi et al., 1996). Considering that the prevalence of risk for Post-traumatic Stress Disorder (PTSD) in this population could reach up to 10% (Hernández-Martínez et al., 2021), it was estimated that 100 women at risk for PTSD were necessary to enable a multivariate analysis with a minimum of 10 independent variables.

Data collection

Information was collected through an online questionnaire. The questionnaire covered several categories of variables, including sociodemographic data, obstetric history, details of the most recent birth, obstetric practices used, and neonatal outcomes, as well as the Childbirth Abuse and Respect Assessment Questionnaire - Maternal Version (CARE-MQ). This scale is composed of Likert-type questions that address various situations and practices related to obstetric violence (abuse and disrespect during childbirth). Response options range from “It did not occur during my birth” (0 points) to “It occurred and affected me a lot” (3 points), to “It occurred, but it did not affect me” (1 point), to “It occurred and affected me a little” (2 points). The total score ranges from 0 to 60 points. Scores can be categorized according to their percentile distribution (≤50th percentile, 51st-75th percentile, 75th-90th percentile, >90th percentile). The tool has demonstrated adequate internal consistency and excellent temporal stability in test–retest tests (Hernández-Martínez et al., 2024).

This information was already collected from the previous study. To recruit the participating women, we contacted each of the women who participated in the previous study and had expressed interest in continuing to participate in a subsequent follow-up via email. They were again informed and gave their consent to participate, providing a contact phone number or email address to address any questions they may have about the study.

The new questionnaire administered at the 6-month follow-up incorporated the following assessment tools:

• Perinatal Post-traumatic Stress Disorder Scale (PPQ) PTSD risk was assessed using this 14-item Likert-type questionnaire, with total scores ranging from 0 to 56 points (Hernández-Martínez et al., 2021). For this study, high risk for PTSD was defined as a score equal to or greater than the 90th percentile of its distribution.

• Family Apgar. The family Apgar assesses an individual’s perceived satisfaction with five dimensions of family dynamics: Adaptability, Partnership, Growth, Affection, and Resolve (Gómez Clavelina and Ponce Rosas, 2010). The scale comprises five items with three possible Likert-type responses: “Almost never” (0 points), “sometimes” (1 point), and “almost always” (2 points). The total score ranges from 0 to 10 points:

- 0–3 points. Indicates low satisfaction or a dysfunctional family.

- 4–6 points. Indicates medium satisfaction or possible dysfunction.

- 7–10 points indicate high satisfaction in a functional family.

This scale has been validated in the Spanish population, showing good internal consistency (Cronbach’s α from 0.84 to 0.86), as well as adequate construct validity.

Medical Outcomes Study Social Support Survey (MOS-SSS) The MOS-SSS scale is a self-administered instrument designed to assess perceived social support. It consists of 19 items that explore various dimensions of social support, including emotional, instrumental, and affective support, as well as positive social interaction. The full version of the scale has been validated in the Spanish population through a descriptive study with a sample of 903 patients. The results showed excellent internal reliability (Cronbach’s α = 0.96), as well as a consistent unidimensional structure confirmed by exploratory and confirmatory factor analysis (KMO = 0.904; CFI = 0.95; TLI = 0.97; SRMR = 0.05) (Gómez-Campelo et al., 2014).

Statistical analysis

Initially, a descriptive analysis of the data was conducted. Qualitative variables were described using absolute and relative frequencies, while the mean and standard deviation (SD) were calculated for quantitative variables.

Subsequently, the bivariate relationship between the overall CARE-MQ scale (first cutoff) and its dimensions and the overall PPQ scores (at 6 months) was analyzed using Pearson’s correlation coefficient. The next step was to identify the specific aspects of the CARE-MQ that were associated with a higher average PTSD risk score on the PPQ. This was done through an analysis of variance (ANOVA), examining the relationship of each CARE-MQ item with PPQ scores.

Finally, the relationship between sociodemographic, clinical, and birth experience factors and PTSD risk (defined by a PPQ score ≥19 points) was analyzed. All potential confounders were incorporated into this multivariate analysis. Crude and adjusted odds ratios (aORs), along with their respective 95% confidence intervals (95%CIs), were calculated using a binary logistic regression model (Backward Stepwise Regression). All analyses were performed using the statistical program SPSS 29.0.

Results

Sample characteristics

The study initially included 2,912 women who had given birth in the past 18 months. Of these, 479 met the eligibility criteria for having given birth within the first 3 months of the reference period and were invited to participate in the follow-up. In total, 341 women participated, representing a response rate of 71.3%.

The mean age was 33.38 years (SD: 4.23). 91.5% (312) of the pregnancies were planned. The majority of pregnancies were full-term (93.8%, 320), and singleton pregnancies predominated (99.4%, 339). The majority of participants were primiparous (80.1%, 273). Labor was induced in 43.7% (149) of the cases. Oxytocin was used to stimulate labor in 55.7% (190). Regional analgesia was used by 73.6% (251) of the women. Regarding skin-to-skin contact after birth, 62.8% (214) used it for at least 120 min.

Regarding PTSD risk at 6 months, the mean PPQ score was 12.46 (SD = 12.88), with 10.9% (Ford and Ayers, 2011) of women at risk for postpartum PTSD (defined as PPQ > 90th percentile). Meanwhile, the mean CARE-MQ score was 8.27 (SD = 11.56), with 7.6% (Beck and Watson, 2008) of women having a percentile ≥95th (≥31 points). The remaining characteristics of the sample are shown in Table 1.

Table 1

Table 1. Sample characteristics.

Correlation between the CARE-MQ dimensions and PPQ scores at 6-month follow-up

The correlation between the CARE-MQ dimensions and PPQ scores was analyzed, yielding a positive and statistically significant correlation across all dimensions and overall: “Emotional abuse” with r = 0.55 (95% CI: 0.47–0.62), “inadequate treatment by professionals” with r = 0.60 (95% CI: 0.53–0.67), “physical abuse” r = 0.42 (95% CI: 0.33–0.50), and “separation” r = 0.42 (95% CI: 0.33–0.51), which correlated positively (p < 0.001) with PTSD at 6 months. Inadequate treatment by professionals was the element that correlated the most. The correlation between the CARE-MQ score and PPQ at 6 months was 0.63 (95%CI: 0.56–0.69). This relationship is illustrated graphically in Figure 1.

Figure 1

Figure 1. Relationship between CARE-MQ and PPQ scores at 6-month follow-up.

Correlation between the CARE-MQ scores and PPQ scores at 6-month follow-up

Next, to analyze the differences in scores between the CARE-MQ scale and the PPQ scores, an analysis of variance (ANOVA) was performed, revealing a statistically significant linear trend for all items (p < 0.001).

As can be seen in Table 2, there is a significant linear trend (p < 0.001): the greater the perception of negative experiences (from lack of information to physical violence), the higher the PPQ scores and, therefore, the risk of PTSD. The most striking aspects were physical violence, lack of professional support, and lack of clear information.

Table 2

Table 2. Relationship between the dimensions of the CARE-MQ questionnaire and the PPQ questionnaire scores.

Risk of post-traumatic stress

A bivariate analysis was then performed to identify the relationship between various sociodemographic and clinical factors and the risk of postpartum PTSD. As shown in Table 3, a significant association was observed between high scores on the CARE-MQ scale (Figure 2), grouped by percentiles, and an increased risk of developing PTSD. The same was true for women with: previous cesarean section, induced labor, birth plans being disrespected, complicated births, use of regional analgesia, instrumental births, scheduled cesarean section, emergency cesarean section, episiotomy, and hospitalization of the newborn. In contrast, women who had more vaginal births, had skin-to-skin contact for at least 120 min, breastfed within the first hour, and had higher scores on the Family and Social Support (MOS) Apgar score, had lower scores for PTSD.

Table 3

Table 3. Factors associated with the risk of PTSD Bivariate and multivariate analysis.

Figure 2

Figure 2. Relationship between CARE-MQ scores and PPQ scores grouped by percentiles to detect risk for post-traumatic stress disorder.

Finally, a multivariate analysis was performed to control for confounding bias, observing that women with a higher perception of reported obstetric violence had a higher risk of PTSD, specifically the highest probability in the group with score percentiles ≥95, where the odds of PTSD were 48.38 times higher (aOR) (95% CI: 10.07–232.44) compared to those with CARE-MQ scores ≤P50. In this same analysis, it was observed that instrumental birth (aOR: 5.29; 95%CI: 1.53–18.28) and previous cesarean (aOR: 7.54; 95%CI: 1.10–51.79) were more likely to develop PTSD. In contrast, women with greater social support as assessed by the MOS questionnaire were less likely (aOR: 0.96; 95%CI: 0.94–0.99).

Discussion

The results show that 10.9% of women were at risk for PTSD. This prevalence is in line with previous literature, which estimates a prevalence between 3 and 16% depending on the instrument used and the characteristics of the healthcare and sociocultural context (Grekin and O’Hara, 2014; Dekel et al., 2019; Yildiz et al., 2017).

One of the main contributions of this study is the significant association between scores on the CARE-MQ scale, which measures experiences of obstetric violence, and the risk of PTSD. As the impairment in the items on this scale increased, so did the score on the PPQ scale, reinforcing the importance of the perception of childbirth as a potential trigger for psychological trauma (Simpson et al., 2018; Ayers, 2004; Beck and Watson, 2008). This result is supported by existing literature, which has documented the negative impact of obstetric violence and dehumanizing treatment on maternal mental health after childbirth (Slade et al., 2019; Sen et al., 2018; Bohren et al., 2015). Likewise, recent research has shown that the subjective perception of abuse can generate psychological consequences even when the clinical outcomes of childbirth have been favorable (Bohren et al., 2015).

Particularly striking was the finding regarding items 19 and 16 of the CARE-MQ, which refer to physical aggression, showing the highest mean scores on the PPQ. This result points to the serious impact of experiences that women identify as aggressive or violent during childbirth, although these do not always correspond to situations objectively classified as obstetric violence. This phenomenon has been noted by other authors, who emphasize that the perception of abuse or loss of autonomy can have psychological consequences as important as adverse clinical events (Bohren et al., 2015).

Furthermore, multivariate analysis identified instrumental birth and previous cesarean section as risk factors, consistent with previous findings linking these events with feelings of invasion, loss of control, or lack of consent (Ford and Ayers, 2011; Harris and Ayers, 2012). These experiences can lead to a perception of loss of safety and autonomy in women during childbirth, which is a trigger for postpartum PTSD (Beck, 2004).

Interventions performed during instrumental births can be perceived as invasive experiences, intensifying the negative emotional impact of birth. Qualitative studies have described how women who experience instrumental births feel a lack of participation, reinforcing their sense of trauma (Fenech and Thomson, 2014; Söderquist et al., 2009). Similarly, multiple studies have found that non-eutocic births, especially when unexpected or performed without sufficient information or consent, increase the risk of PTSD (Czarnocka and Slade, 2000; Ford and Ayers, 2011; Fenech and Thomson, 2014).

Conversely, perceived social support, assessed using the MOS questionnaire, was associated with a lower likelihood of developing PTSD, which is consistent with studies demonstrating that an emotional support network acts as a key protective factor in potentially traumatic situations (Milgrom et al., 2019; Leight et al., 2010). Furthermore, it corroborates that emotional support contributes to a more positive birth experience by facilitating the validation of experienced emotions and reducing feelings of isolation or perceived failure that can arise after complicated births (Tani and Castagna, 2017).

Among the strengths of this study are the combined use of validated tools for assessing PTSD (PPQ) and negative experiences in care (CARE-MQ), as well as the multivariate analysis to control for confounding variables. However, some limitations should be noted. First, the observational design prevents the establishment of causal relationships. Second, the PTSD assessment was based on a screening scale and not a clinical diagnosis. A further limitation is the lack of statistical power due to the sample size, meaning that variables traditionally associated with a higher risk of PTSD were not included in our study.

The results support the need to implement systematic tools for assessing negative childbirth experiences, such as the CARE-MQ questionnaire, which could be integrated into postpartum care to identify women at risk and provide them with early psychological care. Furthermore, the study highlights the importance of training healthcare professionals in communication skills and in managing complex obstetric situations from a woman-centered perspective (Balde et al., 2020).

Moreover, the interpretation of these results must be contextualized within the Spanish cultural and healthcare model, which is characterized by predominantly hospital-based childbirth care and a high use of obstetric interventions compared with other European countries (Euro-Peristat Project, 2022). This environment may influence women’s perceptions, as highly medicalized practices may be experienced either as routine or, conversely, as invasive in the absence of adequate communication. Likewise, the growing social and regulatory debate on obstetric violence in Spain—driven by international organizations such as the WHO (World Health Organization, 2014) and by reproductive rights advocacy movements—may increase sensitivity toward experiences perceived as disrespectful. These cultural and systemic factors should be considered when interpreting the findings and when assessing their generalizability to contexts with less medicalized models of care or greater continuity of care (El Parto es Nuestro, 2020).

Conclusion

This study highlights the relationship between the quality of obstetric care, negative experiences during childbirth, and the risk of postpartum post-traumatic stress disorder at 6-month follow-up. The results indicate that the greater the perception of obstetric violence, the greater the risk of developing postpartum PTSD. Inadequate treatment by providers was the CARE-MQ scale item most strongly correlated with the risk of PTSD. A significant and linear association exists between higher scores on the CARE-MQ scale items and higher PPQ scores at the 6-month follow-up. Risk factors identified for developing PTSD include instrumental birth and previous cesarean section, with greater social support being a protective factor for PTSD.

This evidence reinforces the need to move toward a more humanized, woman-centered model of care based on respect, autonomy, and empathy as key elements for safety, not only physical but also emotional and psychological.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by Mancha-Centro Hospital (197-C), Reina Sofía University Hospital of Córdoba (5615), and Ciudad Real University Hospital (C-600). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

IO-E: Conceptualization, Data curation, Investigation, Writing – original draft. VM-P: Investigation, Methodology, Visualization, Writing – original draft. JM-G: Conceptualization, Funding acquisition, Methodology, Resources, Writing – review & editing. AB-C: Conceptualization, Investigation, Validation, Writing – review & editing. SM-R: Investigation, Software, Supervision, Writing – review & editing. AH-M: Conceptualization, Funding acquisition, Methodology, Resources, Software, Writing – review & editing.

Funding

The author(s) declared that financial support was received for this work and/or its publication. This research was financed by the Instituto de Salud Carlos III (project PI22/00541) with co-funding from the European Union.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Correction note

A correction has been made to this article. Details can be found at: 10.3389/fpsyg.2026.1777503.

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The author(s) declared that Generative AI was not used in the creation of this manuscript.

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