We thank Drs Dekel and Hughes for their thoughtful Letter regarding our Expert Review on childbirth-related posttraumatic stress disorder (PTSD) and postpartum depression (PPD) following cesarean delivery.
We agree that the overlap between trauma-related and depressive symptoms in the postpartum period is clinically important. In our review, we chose to address PTSD and PPD separately to simplify key messages and because the existing literature most often examines these conditions independently. Moreover, data specifically assessing their comorbidity after cesarean delivery remain limited. Importantly, robust longitudinal studies jointly evaluating PTSD and depressive symptoms at repeated postpartum time points are needed to better characterize temporal patterns and bidirectional relationships and to guide evidence-based screening strategies.
Regarding screening, we agree that relying solely on depression screening may fail to identify trauma-related symptoms following a traumatic cesarean delivery. However, from a pragmatic obstetric perspective, multiplying screening instruments is unlikely to be feasible in routine care. This highlights the need to validate simple, integrated approaches that can first identify traumatic birth experiences or high-risk contexts and then prompt targeted assessment for trauma-related disorders when appropriate rather than prioritizing depression screening alone. Timing is also critical, as PTSD diagnosis requires symptoms persisting beyond 1 month, whereas acute stress reactions are common in the immediate postpartum period. In addition, cesarean deliveries experienced as traumatic are not always recognized as such by care providers, underscoring the importance of standardizing early identification of high-risk contexts in the immediate postpartum period.
Finally, we fully agree on the importance of distinguishing Diagnostic and Statistical Manual of Mental Disorders 5th version–defined PTSD, which requires Criterion A exposure, from broader traumatic childbirth experiences and posttraumatic stress symptoms. As emphasized in our review, heterogeneity in definitions and measurement tools likely contributes to variable and inflated prevalence estimates. At the same time, from a screening and prevention perspective, clinically meaningful distress and functional impairment may occur even when full PTSD criteria are not met. Identifying posttraumatic stress symptom profiles remains essential to avoid missed opportunities for early support and appropriate referral, and such profiles may also be associated with an increased risk of PPD.
Ultimately, postpartum screening should primarily serve a preventive purpose by enabling early identification of distress and prompt referral to perinatal mental health specialists, who can ensure accurate diagnosis and appropriate management.
The authors report no conflict of interest.
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