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Abstract

Background
Childbirth is a complex event where the quality of care may profoundly be linked to women’s experiences and subsequent psychological wellbeing. Adverse childbirth experiences can be associated with to childbirth-related post-traumatic stress disorder. Conversely, positive care experiences, specifically supportive interactions and respectful treatment, may act as a protective factor associated with maternal resilience.

Aim
This study aimed to investigate how medical events during childbirth, including birth complications and interventions, align with the quality of childbirth care. It evaluated the relationship between positive (person-centred care) and negative (mistreatment) care-related factors on perceived threat and subsequent childbirth-related post-traumatic stress symptoms (CB-PTSS).

Methods
This cross-sectional analysis utilised data from 683 mothers/birthing people collected at 8-weeks postpartum as part of a large German prospective cohort study, RESPECTPARENTS (N=1300).
Structural Equation Modelling (SEM) was employed to examine the direct and indirect paths connecting predictor variables (birth complications and interventions) to outcome variables of perceived threat and childbirth-related post-traumatic stress symptoms using positive care-related factors (person-centred care) and negative care-related interaction (mistreatment) as potential mediating variables.

Results
Results confirmed that birth complications demonstrated a significant positive association with higher perceived threat (β = 0.152, 95% CI [0.062, 0.238], p < .001) and CB-PTSS (β = 0.158, 95% CI [0.083, 0.236], p < .001). Person-centred care was inversely related to perceived threat (β = -0.107, 95% CI [-0.196, -0.014], p = .022) and lower CB-PTSS (β = -0.255, 95% CI [-0.336, -0.173], p < .001). Mistreatment during childbirth significantly mediated the relationship between birth interventions and CB-PTSS (β = 0.032, 95% CI [0.015, 0.062], p = 0.004), though the magnitude of this indirect effect was small (β = 0.032, 95% CI [0.015, 0.062], p = 0.004).

Discussion
This study confirms that birth complications are associated with higher perceived threat and CB-PTSS. Critically, the mediation finding highlights that negative experiences of care during childbirth may be an important factor in to trauma development. Beyond the mediation pathway, the direct protective effect of positive care-related factors on perceived threat and CB-PTSS is particularly noteworthy. This underscores that the subjective experience of care during childbirth is a key associated risk factor for birth trauma, independent of obstetric procedures.

Conclusion
These findings highlight the necessity of person-centered, trauma-informed childbirth care supported by empowering healthcare policies. By demonstrating that care-related factors are directly associated with perceived threat and CB-PTSS risk, this study underscores the critical responsibility of healthcare professionals in shaping psychological outcomes through respectful practice.

Publication Type:	Article
Additional Information:	© 2026 The Author(s). Published by Elsevier Ltd. Under a Creative Commons license.
Publisher Keywords:	childbirth, perceived threat, post-traumatic stress disorder, childbirth care, mistreatment, person-centred care, birth complications, birth interventions, path analysis
Subjects:	H Social Sciences > HM Sociology H Social Sciences > HN Social history and conditions. Social problems. Social reform R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine R Medicine > RG Gynecology and obstetrics
Departments:	School of Health & Medical Sciences School of Health & Medical Sciences > Department of Nursing & Midwifery
SWORD Depositor:	Symplectic Administrator

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