Assessing Perinatal Psychiatric Morbidity: Implications for Maternal Mental Health Care in Italy

Pregnancy and childbirth bring significant physical, psychological, and social changes. The perinatal period, which extends from the beginning of pregnancy to one year postpartum, is a complex and vulnerable time that presents various challenges for both women and men in the transition to parenthood (Parfitt & Ayers, 2014).

Research suggests that approximately 1 in 3 births are perceived as psychologically traumatic (Alcorn et al., 2010) and meta-analyses show that 4% of women who give birth later develop childbirth-related PTSD (CB-PTSD), while clinically significant CB-PTSD symptoms are observed in 17% of women (Heyne et al., 2022).

The mother-child bond, the emotional and cognitive connection between a mother and her child, is of central importance for the child's development and the mother's well-being. Previous research has shown that poor parent-child attachment has been associated with impaired emotional, behavioural and cognitive development in the child, as well as affective disorders in adulthood (Dekel et al., 2020). Although previous studies have shown how postpartum depression and anxiety can affect mother-infant bonding (Dekel et al., 2020), less is known about the potential impact of birth-related PTSD.

Traumatic birth experiences and the resulting CB-PTSD symptoms can cause considerable distress and have a significant long-term impact on the health of women, their babies and their families. It is now well established that maternal CB-PTSD can affect both maternal and spousal relationships (Garthus-Niegel et al., 2018; Hairston et al., 2018) and can also lead to long-term negative effects on child behaviour and development (e.g. Cook et al., 2018).

Traumatic births can also affect medical staff (Uddin et al., 2022), resulting in significant costs to healthcare systems and potential economic consequences for society (Bauer et al., 2014). Therefore, the prevention of traumatic births and CB-PTSD is a global priority. This mandate is in line with the United Nations Millennium and Sustainable Development Goals for better health for women, mothers and children (United Nations DESA, 2022), the World Health Organisation’s call for dignified and respectful maternity care for every woman (WHO, 2015) and the Council of Europe and European Parliament’s resolution on the importance of women’s sexual and reproductive rights (European Parliament, 2022). Although a recent systematic review of the cost-effectiveness of interventions for perinatal disorders, including CB-PTSD, concluded that screening, psychological or social support and specialised treatment programs are all effective and cost-effective interventions to address these issues (Verbeke et al., 2022), screening for CB-PTSD is often neglected among perinatal mental disorders (PMDs). Currently, only a handful of countries have developed strategies to prevent traumatic births and treat CB-PTSD (Thomson et al., 2021). Even in the World Health Organisation’s recommendations on maternal and newborn care for a positive postnatal experience (WHO, 2022), only depression and anxiety are mentioned in the few lines dedicated to mental health. The lack of clear policies or guidelines means that many people have limited access to the services they need (Sperlich et al., 2017).

Since 1978, the Italian National Health Service (Servizio Sanitario Nazionale, SSN) has guaranteed universal access to healthcare. The central government determines the national core benefits package and provides funding for the regional healthcare systems. The 19 Italian regions and two autonomous provinces are responsible for funding, planning and providing services at the local level, supported by a network of around 100 local health authorities (Signorelli et al., 2020). Significant differences exist in the provision of healthcare services across the country (Cicchetti & Gasbarrini, 2016). In Italy, there is no specialised service for perinatal mental health, so mental health care for women of childbearing age is provided by mental health departments (MHDs; Grussu et al., 2020). Family Care Centres (FCCs), which are integrated into SSN community services, provide free support to women during pregnancy and in the postnatal period and focus on the early identification of perinatal mental health problems (Grussu et al., 2020). A national guideline for perinatal mental health care is currently not available (Lega et al., 2024). In addition, healthcare providers often have limited training in selecting the most appropriate screening tool and determining the appropriate cut-off point for specific time periods (Cena et al., 2020). Despite these findings, recent research suggests that the prevalence of perinatal mental disorders (PMDs) in Italy is similar to other European countries (e.g. Camoni et al., 2023; Ciuffo et al., in preparation), so there is currently a lack of knowledge about how the national mental health service supports women during the perinatal period. The first study providing insights into the availability of evidence-based best practices for perinatal mental health (PMH) within the Italian mental health service dates back to 2024 (Lega et al., 2024). However, recommendations on prevention and screening for CB-PTSD are still lacking.

The predominant perinatal mental disorders that occur in women during pregnancy and postpartum are depressive syndromes and anxiety syndromes (Cena et al., 2020). Comorbidity of these disorders is common, reaching 40% in some studies (i.e., Misri & Swift, 2015). Research indicates that CB-PTSD is often comorbid with depression and anxiety disorders (i.e., Horesh et al., 2017), which increases the likelihood of postpartum psychiatric problems in women with CB-PTSD. Of women diagnosed with PTSD, 65% also exhibit symptoms of postpartum depression (PPD), while 22% of women with PPD also exhibit symptoms of PTSD (Söderquist et al., 2006). Due to the frequent overlap of these syndromes, it is important to consider how these factors interact with maternal mental health (Grisbrook & Letourneau, 2021). The failure to include recommendations for CB-PTSD screening in existing guidelines may be due to a failure to recognise the prevalence and impact of CB-PTSD on maternal quality of life and family functioning, and the need for validated screening tools (Grisbrook & Letourneau, 2021).

Against this background, the present study aims to investigate the prevalence of CB-PTSD, PPD, and anxiety, along with their comorbidity, in a sample of Italian women 6–12 weeks postpartum, as well as to assess the impact of potential comorbidities on mother-child bonding.

Materials and Method

Results

The sample consisted of 175 Italian women with a mean age of 32.75 years (SD = 4.68). The majority were either married or cohabiting (93.7%), and 60.6% had attained higher education. In terms of employment, most participants were engaged in professional, office, or technical occupations, while a small percentage were unemployed or homemakers. All participants were primiparous, and the majority (74.0%) had a vaginal birth, with 34.7% experiencing minor maternal complications during delivery. Infant complications were reported in 11.1% of cases. Additionally, 28.2% had experienced a previous pregnancy loss, and 12.8% reported uncertainty regarding a past diagnosis of mental illness. Table S1 (Supplementary Materials – see Ciuffo et al., 2025S) summaries the main demographic characteristics and obstetric information of the mothers.

Table 1 shows the prevalence rates of psychiatric disorders and the distribution of specific diagnostic criteria to provide a comprehensive understanding of symptom patterns and diagnostic thresholds.

The cross-tabulation analysis between postnatal depression and anxiety showed a significant correlation. Of the 175 participants, 159 gave valid responses (90.9%), while 16 were missing (9.1%). Of the women with valid data, 84 met the criteria for either depression or anxiety: 46 women met the criteria for anxiety but not for depression, 27 women met the criteria for depression but not for anxiety, and two women met the requirements for both. The remaining nine cases were women who did not fulfil the criteria for either disorder. The chi-square test for independence showed a statistically significant relationship between depression and anxiety, χ²(1, N = 84) = 9.131, p = .003. This was further confirmed by the likelihood ratio, χ²(1, N = 159) = 11.258, p < .001, and Fisher’s exact test, p (bilateral) = .002. These results suggest that the presence of depression is significantly associated with an increased likelihood of anxiety in postpartum women.

The association between CB-PTSS and anxiety was examined in 158 valid cases (90.3%) and 17 missing cases (9.7%). The distribution was as follows: 33 women met criteria for neither CB-PTSS nor anxiety, 19 women met criteria for anxiety but did not have CB-PTSS, 78 women met criteria for CB-PTSS but not anxiety, and 28 women met criteria for both. The chi-square test showed no statistically significant association between PTSS and anxiety, χ²(1, N = 158) = 1.711, p = .191. The likelihood ratio, χ²(1, N = 158) = 1.680, p = .195, and Fisher’s exact test, p (bilateral) = .200, also showed no significant association. This suggests that the presence of PTSD symptoms related to childbirth was not significantly correlated with anxiety in this sample.

For the relationship between CB-PTSS and postnatal depression, there were 171 valid cases (97.7%) and 4 missing cases (2.3%). The results of the contingency table were as follows: 52 women did not meet criteria for either CB-PTSS or depression, two women met criteria for depression but not CB-PTSS, 87 women met criteria for CB-PTSS but not depression, and 30 women met criteria for both. The chi-square test showed a statistically significant association between CB-PTSS and depression, χ²(1, N = 171) = 11.689, p < .001. The likelihood ratio, χ²(1, N = 171) = 14.541, p < .001, and Fisher’s exact test, p (bilateral) < .001, confirmed this significant association. These results suggest that women with postnatal depression are more likely to experience PTSD symptoms related to childbirth.

Finally, a hierarchical regression model was developed to examine the effects of individual and comorbid disorders on mother-infant attachment 6-12 weeks postpartum. In Step 1, depression was used as a predictor of attachment, in Step 2 anxiety was integrated, in Step 3 the CB-PTSS (birth-related symptoms and general symptoms) and in Step 4 the covariates were added. Depression was found to be a significant predictor of disturbed mother-infant attachment and explained 28% of the variance. This suggests that higher levels of postpartum depression are associated with poorer attachment. The addition of anxiety did not significantly improve the model, suggesting that anxiety is not a strong predictor of mother-infant attachment in this sample. When birth-related and general PTSD symptoms were added, the model improved significantly, with general PTSD symptoms being a particularly strong predictor. This model explained 34.8% of the variance, suggesting that trauma-related symptoms play a significant role in mother-infant attachment. The inclusion of additional covariates (such as type of birth and pre-existing mental health diagnoses) did not further improve the model, suggesting that these variables do not have a significant impact on mother-infant attachment in this context. The following table (Table 2) summaries these results.

Discussion

Perinatal mental disorders are widespread and represent a major health problem. Awareness, prevalence rates and treatment of these mental disorders vary greatly from country to country (i.e., Dikmen-Yildiz et al., 2017). The present study aimed to investigate the prevalence and comorbidity of CB-PTSD, PPD and anxiety in a sample of Italian women 6-12 weeks postpartum. In addition, the effects of these potential comorbidities on mother-infant bonding were investigated.

In terms of prevalence rates, depression and anxiety were similar to previous literature (i.e., Hahn-Holbrook et al., 2018), while CB-PTSD was slightly lower than the observed global pooled prevalence (Heyne et al., 2022), albeit similar to previous studies (i.e., Dikmen-Yildiz et al., 2017). Although only 1.1% of women met the full diagnostic criteria for CB-PTSD, the vast majority of mothers (68.4%) had one or more CB-PTSS, demonstrating how prevalent this pathology is in this population. In addition, the results confirmed the co-occurrence of childbirth-related PTSD symptoms and depression in 17.54% of the sample, similar to previous research in this field (Dekel et al., 2020), suggesting that women with depression are more likely to have CB-PTSS and vice versa. In our sample, we found no significant association between CB-PTSS and anxiety. However, previous studies (Dikmen-Yildiz et al., 2017) have found increased comorbidity between these disorders 6 months postpartum. This suggests that the co-occurrence of these disorders becomes more evident later in the postpartum period as conditions become more structured. Longitudinal studies are needed to investigate these associations throughout the postpartum period. The presence of comorbidities indicates that if depression or PTSD is suspected, it is important to look at other symptoms for treatment purposes. It may also be beneficial to consider these disorders as part of a continuum of stress and to use the term ‘postnatal mood disorders’ proposed by Matthey et al. (2003), which includes birth-related PTSD. There is extensive evidence that early assessment of PPD can predict maternal attachment difficulties up to one year postpartum (e.g. Kasamatsu et al., 2020), but there is considerably less research examining the relationship between attachment and other psychopathologies such as CB-PTSD. Women with comorbid mental disorders are more likely to have impaired functioning and experience higher levels of stress than women with only one disorder (e.g. Horesh et al., 2017). Although PPD is widely recognised as a significant risk factor for poor attachment, the relationship between CB-PTSD and attachment is less well understood. Some studies have found a clear association between CB-PTSD and impaired attachment (Parfitt et al., 2014), while others have not observed such an association (Nakić Radoš et al., 2020). This inconsistency may be due to differences in the definition of CB-PTSD, the methods used to measure it, and the consideration of other factors, such as comorbid depression (Davies et al., 2008). Our findings suggest that the effects of CB-PTSD on attachment may vary from person to person. In particular, symptoms of CB-PTSD, especially when combined with depression, appear to disrupt emotional bonding between mothers and their infants. In contrast, birth-related PTSD symptoms alone appear to have less of an impact on attachment. This is consistent with recent research that distinguishes between birth-related and more general PTSD symptoms (e.g. Nakić Radoš et al., 2020), with general PTSD symptoms showing a stronger association with impaired attachment.

As mentioned above, the lack of recommendations for CB-PTSD screening in existing guidelines may be due to a lack of awareness of the prevalence and impact of CB-PTSD on maternal quality of life and family functioning, as well as the need for validated screening tools (Grisbrook & Letourneau, 2021). Indeed, a recent systematic review (Ciuffo et al., 2025) highlighted that a challenge in screening for CB-PTSD is the limited availability of validated questionnaires specifically designed to assess this disorder.

The lack of customised instruments also makes it difficult to determine the true prevalence of the disorder, which remains poorly researched and overlooked in Italian maternity facilities (Ciuffo et al., in press). Screening needs to take into account organisational factors that affect implementation as well as the availability of valid measurement tools to accurately identify the disorder. To date, the City Birth Trauma Scale (City BiTS; Ayers et al., 2018) is the only self-report specifically designed to measure CB-PTSD according to DSM-5 diagnostic criteria and validated for the Italian population (Ciuffo et al., in press). The City BiTS-IT has good reliability and strong psychometric properties. It is a quick and straightforward instrument, making it highly recommended for the early detection of childbirth-related PTSD (Ciuffo et al., in press).

In 2019, an international consortium of researchers and clinicians specialising in traumatic birth and CB-PTSD was established to advance knowledge and practise in this area (European Commission Cooperation in Science and Technology (COST Action grant CA18211). This group developed recommendations for practise, research and policy (Ayers et al., 2024). In terms of research, the use of “CB-PTSD validated, diagnosis-based instruments is required. To determine diagnoses and prevalence, cut-off values need to be established and adapted to different cultural settings”. Substantial evidence of the prevalence and consequences of CB-PTSD will facilitate the assessment of the economic burden associated with this condition, thus providing a sound rationale and financial motivation for prioritising prevention and intervention efforts in areas that are currently under-supported in health systems worldwide (Ayers et al., 2024).