Perinatal Posttraumatic Stress
Screening parents when care is needed most
The Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ) is a brief screen for the traumatic stress that can follow a difficult birth or a neonatal intensive care stay. It was developed so that the staff closest to parents can identify who is struggling while parents are still within reach of help.
Posttraumatic stress after a frightening birth or intensive care stay is a common response to a hard experience and never a failing on the part of a parent. It matters because parents’ emotional well-being supports a healthy parent-baby relationship and the long-term well-being of parents, babies, and families (Hynan et al., 2015). The PPQ is a screen. A positive score is a signal to offer support, and it is not a diagnosis.
Why the Questionnaire Exists
The parent is not the patient
When an infant is critically ill, every clinician at the bedside is focused on the infant. The parent is in crisis too, but is not the patient, so the parent’s distress can go unnoticed. Avoidance is also a core feature of posttraumatic stress, so the parents most affected may be the least likely to ask for help.
A measure the nearest staff can use
The PPQ is short, tied to the birth event, and scored against a single cutoff. It was developed so that the people nearest to parents can use it. National recommendations state that screens can be delegated to unit staff who are trained and supervised, and note that some units have had success with the bedside nurse administering them (Hynan et al., 2015).
The Scale of the Problem
The Measure
What it asks
The PPQ has 14 items covering intrusion, avoidance and numbing, and hyperarousal, plus one item on guilt. The modified version (PPQ-II) rates each item from 0 to 4 for a total of 0 to 56. A score of 19 or higher is treated as a positive screen.
How it performs
The PPQ-II shows good internal consistency (alpha = .90 in a Polish validation) and convergent validity with other posttraumatic stress measures (r = .43 to .85) (Szablewska et al., 2025). In a Spanish validation, three components explained 63.3% of the variance, and scores identified risk of postnatal depression with an area under the curve of .86 (Hernández-Martínez et al., 2021). The questionnaire has also been used to study postpartum posttraumatic stress in China (Liu et al., 2021).
From Screening to Care
A screen helps only if a positive result leads somewhere. Consensus recommendations describe three tiers of support in the unit (Hynan et al., 2015).
Universal
Family-centered care, education about stress reactions, and trained peer support offered to every parent.
Targeted
Support from social workers, psychologists, or trained unit staff for parents with risk factors or acute distress.
Clinical
Referral for psychological or psychiatric treatment when symptoms exceed what the unit can manage.
A meta-analysis of 160 studies and 16,639 parents associated psychotherapy and emotional support in the unit with the largest reductions in parent anxiety, and psychotherapy with reductions in stress and depression (Niehaus Milligan et al., 2026).
Why This Matters in North Texas
Infant loss in North Texas
| Area | Infant deaths per 1,000 live births, 2024 |
|---|---|
| Dallas County | 5.97 |
| Tarrant County | 5.63 |
| Collin County | 5.20 |
| Denton County | 4.13 |
| Texas | 5.73 |
| United States | 5.53 |
| Healthy People 2030 goal | 5.00 |
Provisional 2024 rates for North Texas counties with at least 10,000 live births. Source: Tarrant County Public Health (2025).
Early birth
Prematurity and low birth weight were the second leading cause of infant death in Tarrant County from 2020 to 2024, accounting for 16.2% of infant deaths, after birth defects at 25.4%. Tarrant County had the fourth highest infant mortality rate among the nine Texas counties with at least 10,000 live births in 2024.
Each early birth and each infant loss involves parents who need support while their infant is hospitalized and afterward.
Use and Permission
The PPQ is in the public domain, and clinicians and researchers are welcome to use it. Please contact the CARE Lab with questions about versions, translations, or scoring.
References
- Callahan, J. L., & Borja, S. E. (2008). Psychological outcomes and measurement of maternal posttraumatic stress disorder (PTSD) during the perinatal period. Journal of Perinatal and Neonatal Nursing, 22(1), 50-60. https://doi.org/10.1097/01.JPN.0000311875.38452.26
- Callahan, J. L., & Hynan, M. T. (2002). Identifying mothers at risk for postnatal emotional distress: Further evidence for the validity of the Perinatal Posttraumatic Stress Disorder Questionnaire. Journal of Perinatology, 22(6), 448-454. https://doi.org/10.1038/sj.jp.7210783
- Callahan, J. L., Borja, S. E., & Hynan, M. T. (2006). Modification of the Perinatal PTSD Questionnaire to enhance clinical utility. Journal of Perinatology, 26(9), 533-539. https://doi.org/10.1038/sj.jp.7211562
- Hernández-Martínez, A., Martínez-Vázquez, S., Rodríguez-Almagro, J., Khan, K. S., Delgado-Rodríguez, M., & Martínez-Galiano, J. M. (2021). Validation of perinatal post-traumatic stress disorder questionnaire for Spanish women during the postpartum period. Scientific Reports, 11(1), Article 5567. https://doi.org/10.1038/s41598-021-85144-2
- Hynan, M. T., Steinberg, Z., Baker, L., Cicco, R., Geller, P. A., Lassen, S., Milford, C., Mounts, K. O., Patterson, C., Saxton, S., Segre, L., & Stuebe, A. (2015). Recommendations for mental health professionals in the NICU. Journal of Perinatology, 35(S1), S14-S18. https://doi.org/10.1038/jp.2015.144
- Jawed, A. (2026). Significance of perinatal trauma screening and care coordination to improve infant health outcomes. Journal of Perinatal Medicine. https://doi.org/10.1515/jpm-2025-0683
- Liu, Y., Zhang, L., Guo, N., & Jiang, H. (2021). Postpartum depression and postpartum post-traumatic stress disorder: Prevalence and associated factors. BMC Psychiatry, 21(1), Article 487. https://doi.org/10.1186/s12888-021-03432-7
- Muller, K. S., van Oers, H. A., Meesters, N. J., Obermann-Borst, S. A., Aarnoudse-Moens, C. S. H., Tataranno, M. L., Lopriore, E., Raets, M. M. A., van Ganzewinkel, C., Dijk, P. H., van den Akker, C. H. P., de Boode, W. P., Schuerman, F. A. B. A., van Kaam, A. H., Reiss, I. K. M., Simons, S. H. P., van den Bosch, G. E., & Haverman, L. (2026). Parent mental health from preterm birth through the NICU stay. Pediatrics, 158(3), Article e2026076477. https://doi.org/10.1542/peds.2026-076477
- Niehaus Milligan, C. E., Hayes Austin, L. R., Auckland, P., Hatfield, O., Bills, S. E., Daffin, M., Keith, J., Genova, G., Black, A., Tsujimoto, K., & Korczak, D. (2026). Parent mental health interventions in the NICU: A systematic review and meta-analysis. JAMA Pediatrics, 180(9), 975. https://doi.org/10.1001/jamapediatrics.2026.2546
- Swenson, S. A., Paulsen, M. E., Carrigan, K., Stover-Haney, R., Wilton, D., Skalland, B., Lampland, A. L., Diego, E., Kroupina, M., Osterholm, E. A., & Downey, A. (2025). Implementation of perinatal mental health screening for parents of infants in a level IV neonatal intensive care unit: A quality improvement initiative. Journal of Perinatology, 45(6), 859-866. https://doi.org/10.1038/s41372-025-02315-z
- Szablewska, A. W., Wójcicka, L., Prajzner, A., Zdun-Ryżewska, A., Burdecka, J., & Klasa-Mazurkiewicz, D. (2025). Validation of the Polish PPQ-II: Sociodemographic and clinical correlates of perinatal PTSD. Frontiers in Psychology, 16, Article 1698527. https://doi.org/10.3389/fpsyg.2025.1698527
- Tarrant County Public Health. (2025, December). Infant mortality in Tarrant County [Data brief]. https://www.tarrantcountytx.gov/content/dam/main/public-health/PH%20DOCUMENTS/Epi/Data%20Briefs/2025/2025-12_Data_Brief_Infant_Mortality.pdf