Unmasking Distorted Reflections: Exploring Body Image, Alcohol, and Drug Use in Nighttime Entertainment Districts.

Background: Violence within nighttime entertainment districts (NEDs) has been blamed on problematic masculinity and has predominantly been attributed to excessive alcohol intake and steroid use in men. In this report we conducted two studies to: (1) ascertain whether researchers could act as third-party raters of body weight and muscle mass in NED patrons; and (2) to examine the relationship between body self-image, inebriation, alcohol preloading behaviors and drug use in the NEDs. Methods: Study 1 employed an observational approach to establish inter-rater reliability for ratings of muscle mass and weight. In Study 2 data (n = 2,745) were collected through breathalyzing and questionnaires to examine individuals' self-image and drinking and drug-taking behaviors. Results: Participants' self-ratings of muscle and weight significantly differed from researchers' ratings, with males perceiving themselves as less muscular and females perceiving themselves as heavier. Perceived weight and muscle size did not relate to alcohol levels, but an interaction was found for female steroid users who perceived themselves as less muscular. Conclusions: Findings indicated a distortion in participants' perceived body image, with a desire for muscularity among both males and females. These results underscore the complex interplay between self-perception, societal ideals, and drug use in young NED patrons.

Preloading with drugs before entry to the nighttime entertainment district: presentation, intoxication rates, and effects of police presence during assessment.

BACKGROUND: Past research has either focused on alcohol or drug preloading before a night out, but not on the interaction between them. With increased risks of harm through interaction effects, we wished to build upon previous research in this area. We sought to determine who drug preloads, why do people engage in this practice, what drug/s are people using, and how inebriated they are as they enter the NED. Additionally, we examined what impact varying levels of police presence has on the collections of sensitive data in this context. METHODS: We captured estimates of drug and alcohol preloading from 4723 people entering nighttime entertainment districts (NEDs) in Queensland, Australia. Data collection occurred under three varying conditions of police presence (i.e., no police present, police present but not engaging with participants, and police engaging with participants). RESULTS: People who admitted to preloading drugs were found to be younger in age than non-drug admitters, more likely to be male than female, use one type of drug (mostly stimulants) rather than multiple (if we exclude alcohol), significantly more intoxicated upon arrival, and more subjectively affected from their use of alcohol and drugs as Breath Approximated Alcohol Concertation levels increased. People were more likely to admit having used drugs in the absence of police, but this had only a small effect. CONCLUSIONS: People who drug preload are a vulnerable subset of the youth population that is susceptible to experiencing harms in this context. As they drink more alcohol, they experience higher affects than those who do not report to also take drugs. Police engagement through service rather than force may mitigate some risks. Further enquiry is needed to better understand those who engage in this practice and to have quick, cheap, objective tests of what drugs these people are using.

Pre-Loading with Drugs before Entering the Nighttime Entertainment District: A Scoping Review.

Background: Nighttime entertainment districts attract many people who pre-load with alcohol and other substances before entering licensed venues. Despite the harms and dangers associated with both alcohol pre-loading and drug use respectively, there is a paucity of research on drug and polysubstance pre-loading. Objectives: The primary objectives of this scoping review are to systematically map out the body of existing literature on drug and polysubstance pre-loading, discuss methodological potentials and pitfalls in field-based research, identify gaps in knowledge, and derive practical implications and opportunities for future research. Methods: Using the PRISMA (ScR) guidelines, we conducted a search of Medline, PsycINFO, Embase, Scopus, CINAHL, Social Services Abstracts, Sociological Abstracts, and Web of Science databases. We followed this up by conducting an author and citation analysis of relevant articles. Results: Of the 632 data sources identified, 338 articles were reviewed after removing duplicates. Overall, only nine articles were included and thematically analyzed. In our review and analysis of the literature, we find people who drug pre-load to be a particularly vulnerable subset of the population. We also posit that the point-of-entry design has greater sensitivity than the commonly used portal-in design. From this, we also draw attention to various time points where field-based researchers can provide intervention. Conclusions: Given the high prevalence of young adults engaging in the behavior, clinicians should consider pre-loading behaviors when assessing for risk and vulnerability. Field-based research would elucidate the full breadth and scope of the growing pre-loading phenomenon and the dangers associated with this practice.

This is the rhythm of the night: Examining the phases of a night-out on preloading motivations and intentions to backload.

BACKGROUND: Field research into the preloading phenomena has rarely examined how patrons move and transition into target events. We conceptualised three phases of the night (PotN) - entering, within and leaving - which a patron can be intercepted by a research group. Our research tested the differences between the PotN on preloading, preloading motivations and alcohol consuming behaviours in a popular night-time entertainment district (NED). METHODS: The sample comprised 1,585 young-adult patrons (934 Men, 651 Women; ages 18-27 years) collected in a cross-sectional design over three PotN. We measured the patron's preloading motivations, current alcohol intoxication and backloading intentions between three different phases of a night-out on Thursday, Friday and Saturday nights, from 9:00p.m. - 4:00 a.m. in Brisbane NEDs (Queensland, Australia). RESULTS: The phases contributed to a difference in preloading rates - one that decreased over the night (p <.001). Between the phases, the motivation of 'saving money' (≈45%) decreased as a reason for preloading and to 'socialise' (≈20%) increased. Enhancement-based preloading motivations (i.e., 'enjoy the feeling' and 'get drunk') were related to increased alcohol intoxication and backloading intentions at different PotN. However, 'saving money' motivations were also associated with a decrease in alcohol intoxication and backloading intentions (i.e., planning to return home to continue alcohol consumption). CONCLUSIONS: Preloading is valued highly by patrons when proximal to the actual preloading. There is a difference between the PotN on preloading rates, preloading motivations, intentions to backload and drinking outcomes as patrons shift from preloading, to entering the NED, to eventually leaving.

Preloading, exit intoxication related to energy drink usage, and gender differences within night-time entertainment districts for young people.

BACKGROUND: Governments frequently introduce legislation to reduce drunkenness and violence in night-time entertainment districts (NEDs). However, there is no study which has looked at inebriation of a large sample of young people exiting a NED. We investigated Breath Approximated Blood Alcohol Concentration (BrAC; grams per decilitre, g/dl) levels as people left Brisbane (Australia) NEDs and measured the effects of preloading, energy drink usage, time of night and gender differences on exit intoxication. METHODS: We systematically assessed patrons between November 2015 to March 2019 by administering surveys and breathalysing them as they exited the NEDs. We then analysed only those under the age of 26 years old (n = 3,211) as there was a natural break in the data on energy drink usage for those aged over 25 years old. FINDINGS: This study found that young drinkers leave the NED with an average BrAC of 0.094 g/dl. Consistent with hypotheses, the exit BrAC was significantly and meaningfully higher in preloaders (medium effect size). These preloaders also came into the NEDs later but stayed for the same length of time as non-preloaders. BrAC levels did not significantly differ for those who did or did not use energy drinks during the night. As predicted, gender was not associated with a meaningful difference in alcohol intoxication and consumption. The time of night that patrons were interviewed was positively associated with inebriation levels, however, this association was small (r ≈ 0.1). DISCUSSION: With preloading being such a strong predictor for end of night intoxication, and length of time spent in the NED equal between those who do or do not preload, we suggest that to have people less inebriated, they should be encouraged into the NED earlier rather than focusing on their leaving time.

The Impact of Last Drinks Legislation: Exit Intoxication and Perceptions of Risk within Nighttime Entertainment Districts in Brisbane, Australia.

BACKGROUND: There is a growing emphasis on reducing alcohol fueled violence. We do not know whether legislation to close nighttime entertainment districts (NEDs) earlier leads to decreased intoxication and fear of violence within the NED. METHODS: We collected data before restrictive alcohol legislation (n = 2,670 participants) and again after legislation was introduced (n = 1,926 participants). Patrons were systematically assessed with surveys and breathalyzers as they exited Brisbane NEDs. RESULTS: Consistent with a 2-hour reduction in closing times, people left the NED substantially earlier. The exit intoxication levels of people did not change between pre- and post-legislation. After the legislation was introduced perceived risk of violence increased. CONCLUSIONS: Perceived alcohol scarcity leads to increased preloading. With only restrictive legislation on alcohol sales, people do not drink to lower levels of inebriation.

The Relationship between Alcohol Hangover Severity, Sleep and Cognitive Performance; a Naturalistic Study.

Alcohol hangover (AH) has been associated with poor sleep due to the negative effects of alcohol intoxication on sleep quantity and sleep quality. The aim of the current study was to further explore the relationship between AH severity and sleep using a naturalistic study design. A further aim was to determine whether quantitative aspects of sleep were a mediating influence on the relationship between AH severity and cognitive performance. As part of the naturalistic study design, 99 drinkers were recruited following a night of drinking in an Australian state capital, with breath alcohol concentration (BrAC) measured as participants were leaving the entertainment district. The following morning at home, participants answered online questions regarding their drinking behaviour on the previous evening, current AH symptoms and sleep quality. Participants also completed an online version of the Trail-Making Test B (TMT-B) to assess cognitive performance. The findings reveal the duration of nightly awakenings to be negatively related to six individual AH symptoms as well as overall AH severity. The number of nightly awakenings, sleep quality and total sleep time correlated with four AH symptoms including overall AH severity. Total AH severity accounted for a moderate amount of variance (11%) in the time to complete the TMT-B. These findings confirm that alcohol consumption negatively affects sleep, which is related to higher next-day hangover severity ratings and poorer cognitive performance.

A Proposal for a Taxonomy of Pre-Loading.

Background: Pre-loading of alcohol and other drugs has become a prevalent start to nights out in many countries. Studies into pre-loading have been using different operational definitions and descriptions, leading to confusion and debate in the research literature. Purpose/Objective: We wish to propose a full taxonomy so that research into preloading, of any substances, can be specific and standardized. Methods: We address this problem by analyzing (1) terminology used throughout the literature, (2) the evolving nature of this phenomenon, and (3) the operational components comprising this substance use practice. Additionally, we provide a context and rationale for how we view pre-loading in relation to the broader event-level session. Results: Our results propose a full operational definition and taxonomy of pre-loading to be used, and built upon, by researchers. We also provide a visual representation of pre-loading within an event-level session and provide a method to facilitate consistency across cultures. Conclusions: We propose that this system will lead to greater specificity and higher reliability in the interpretation of research results.

Drinking to go out or going out to drink? A longitudinal study of alcohol in night-time entertainment districts.

BACKGROUND: Recent research has highlighted the growing trend of alcohol preloading before a night out. We wished to look at people's motivations for preloading, their estimation for drinking during the night, and assess the impact that preloading has on how inebriated people become across the night as measured by Breath Approximated blood Alcohol Content (BrAC). METHOD: We randomly surveyed and breath-tested patrons as they entered and exited Night Time Entertainment Districts (NEDs) in Brisbane, Queensland. We obtained 360 participants who were encouraged to contact us at the end of their night, compensating them for their time with a taxi voucher. Of these, 143 people returned and completed an exit questionnaire. FINDINGS: We found that people were motivated to preload in order to save money and socialise, were likely to drink more than they predicted over the course of the night, and were more surprised by their alcohol reading the higher their BrAC; this trajectory displayed little difference between men and women. It was further found that, for men, personality contributed 19% of the variance to exit BrAC, but entry BrAC accounted for nearly 38% of unique variance. For women, body mass index significantly predicted exit BrAC (9% unique variance), but entry BrAC accounted for nearly 30% unique variance. INTERPRETATION: To reduce general levels of intoxication in city NEDs, interventions should focus on having people come in earlier, less drunk, and be taught to have more realistic appraisals of their drinking.

A big night out getting bigger: Alcohol consumption, arrests and crowd numbers, before and after legislative change.

BACKGROUND: Restrictive practices on alcohol sales in entertainment districts have been introduced to reduce alcohol-related violence in youth. On 1st July 2016, the Queensland State Government (Australia) imposed a 2-hour reduction in trading hours for alcohol sales in venues within specific night-time entertainment districts (NEDS; from 5am to 3am), a reduction in maximum trading hours for venues outside NEDs (with a maximum 2am closing time), the banning of 'rapid intoxication drinks' (e.g. shots) after 12am, and no new approvals for trading hours beyond 10pm for the sale of takeaway alcohol. No independent study has evaluated general levels of intoxication, crowd numbers, fear of violence, and illicit substance use as people enter and exit NEDS, both before and after the introduction of restrictive legislation. Further, no study has assessed the impact using matched times of the year in a controlled study and also assessed actual assault rates as recorded by the police. METHOD: We conducted 3 studies-randomly breath-testing patrons for alcohol, as they entered and exited NEDs. Study 1 assessed patrons' (n = 807) breath approximated blood alcohol concentration (BrAC) and predictions of how the legislation would change their drinking habits before the legislation was enacted. Study 2 assessed crime statistics and patrons' BrAC levels and drug taking reports on an equivalent night, one year apart-before (n = 497) and after (n = 406) the new legislation. Study 3 was a test of the generalisation of Study 2 with two months of survey and BrAC data collected as people entered and exited the NEDs over two consecutive years before (n = 652 and n = 155) and one year after (n = 460) the new legislation. In Study 3 we also collected crime statistics and data on people leaving the entertainment district one year before (n = 502) and one year after (n = 514) the legislative change. FINDINGS: People predicted that the legislation would lead to them drinking more alcohol before they entered town or make little change to their drinking habits. Baseline data over the 2 years before the legislation (Study 3) demonstrated stable preloading rates and BrAC at entry to the NEDs. However, after the introduction of the legislation patrons entered the NEDs systematically later and increased their alcohol preloading. People were substantially more inebriated as they entered the NEDs after the legislative change, with approximately 50% fewer people not preloading after the new laws. Exit BrAC was less consistent but showed some evidence of an increase. Crime statistics and patrons' self-reported experiences of violence did not change. INTERPRETATION: Legislation that does not specifically adapt to the cultural shift of preloading and take local conditions into account will be unsuccessful in reducing alcohol consumption. Such legislation is unlikely to meaningfully change assault rates in youth.

Effects of Alcohol Hangover on Cognitive Performance: Findings from a Field/Internet Mixed Methodology Study.

Results from studies into the cognitive effects of alcohol hangover have been mixed. They also present methodological challenges, often relying on self-reports of alcohol consumption leading to hangover. The current study measured Breath Alcohol Concentration (BAC, which was obtained via breathalyzer) and self-reported drinking behavior during a night out. These were then related to hangover severity and cognitive function, measured over the internet in the same subjects, the following morning. Volunteers were breathalyzed and interviewed as they left the central entertainment district of an Australian state capital. They were provided with a unique identifier and, the following morning, logged on to a website. They completed a number of measures including an online version of the Alcohol Hangover Severity Scale (AHSS), questions regarding number and type of drinks consumed the previous night, and the eTMT-B-a validated, online analogue of the Trail Making Test B (TMT-B) of executive function and working memory. Hangover severity was significantly correlated with one measure only, namely the previous night's Breath Alcohol Concentration (r = 0.228, p = 0.019). Completion time on the eTMT-B was significantly correlated with hangover severity (r = 0.245, p = 0.012), previous night's BAC (r = 0.197, p = 0.041), and time spent dinking (r = 0.376, p < 0.001). These findings confirm that alcohol hangover negatively affects cognitive functioning and that poorer working memory and executive performance correlate with hangover severity. The results also support the utility and certain advantages of using online measures in hangover research.

Crisis support services in night-time entertainment districts: Changes in demand following changes in alcohol legislation.

BACKGROUND: Night time entertainment districts (NEDs) are predominantly frequented by youth who drink alcohol before and after entry. Centres where people binge drink alcohol make use of emergency services at a greater rate than those places where alcohol is not present. Previous UK government research suggests that lengthening the hours for alcohol sales has led to a spreading of emergency service use across the night, with services required later in the night. In Queensland, the State Government has introduced more restrictive opening hours for alcohol sales in NEDs and we predicted earlier use of crisis services and, with a large preloading culture, similar or more service use. METHODS: Volunteer organisations, such as the NightWatch in Brisbane, Australia, provide crisis interventions as required in these NEDs and so we used the data from their records. Every Intervention made by the NightWatch organisation is recorded in an electronic database. We analysed data, matched for time of year, by looking at a 6 month period before the new legislation and a matching 6 month period following legislation. FINDINGS: Following restrictive alcohol sales, the NightWatch provided similar numbers of interventions but those that required a more involved intervention (e.g., Rest and Recovery in a shelter) were significantly more prevalent, while less involved interventions (e.g., Intoxication First Aid provided in situ on the street) were fewer. Consistent with both preloading research and research into hours of alcohol availability, it was found that the NightWatch provided their services to the same number of people as before the legislative change, but provided them earlier in the evening. INTERPRETATION: Where there is a preloading culture, restricting alcohol sales at the end of the night appears to lead to an increased use of crisis interventions earlier in the evening. A compressed need for aid runs the risk of overloading crisis service availability unless these services are proportionately resourced.

An experiment to assess emotional and physiological arousal and personality correlates while imagining deceit.

In order to examine how personality traits, emotional arousal and physiological arousal affect deception confidence, students (N = 102) completed the Eysenck Personality Questionnaire-Revised (EPQ-R) as well as stress and deception tasks while their heart rate variability was measured. Findings indicated psychoticism did not moderate how physiologically aroused participants were while viewing emotionally salient stimuli (video of a road traffic accident) or the thought of enacting deceit, although this came close to significance. However, participants (particularly males) higher in psychoticism reported less subjective distress after imagining enacting deceit than those lower on psychoticism. Extroversion had no impact on physiological arousal when viewing emotionally salient stimuli or thinking about enacting deceit. However, extroverts reported more subjective distress after thinking about enacting deceit than introverts. Also, deception confidence was not correlated to any of these variables. Future research could examine a sample higher in psychoticism and how this trait impacts deception confidence.

Fuel-cell breathalyser use for field research on alcohol intoxication: an independent psychometric evaluation.

BACKGROUND: Several field studies have used fuel-cell breathalysers (FCB) to investigate the prevalence of alcohol intoxication. However, there is a lack of evidence evaluating the psychometric properties of these breathalysers outside of the forensic disciplines. METHODS: The current research describes four studies designed that assess the reliability and validity of portable platinum FCBs for research on alcohol intoxication. Utilising the Alcolizer LE5 breathalyser and, to a lesser degree, the Lifeloc FC-20 and the Lion Intoxilyzer 8000, each study sampled patrons frequenting popular night-time entertainment districts with varying levels of alcohol intoxication. RESULTS: Study one and two found excellent test-retest reliability and inter-instrument reliability for FCBs. Study three and four provided evidence to support the convergent validity of the two FCBs (the LE5 with the FC20), and with an evidential breathalyser (i.e., the Lion Intoxilyzer 8000; EB). DISCUSSION: A 93-97% agreement rate between breathalyser readings was found across the four studies. Portable FCB are recommended as a reliable and valid instrument for research designs requiring quick alcohol intoxication estimations in large populations. Strategies to enhance reliable and valid readings are provided for field researchers.

SmartStart: Results of a large point of entry study into preloading alcohol and associated behaviours.

BACKGROUND: There is a growing trend of preloading with alcohol before entering entertainment districts. It is claimed that this occurs to save money and that preloading may be a good indicator of harmful drinking and risk taking behaviours more generally. No study has collected data from a large sample as the participants entered entertainment districts and measured blood alcohol concentration (BAC) levels and self-reported drinking and risk taking behaviours in a systematic way. METHODS: In this research, police and academics worked together to gauge the breadth and depth of preloading behaviours. In all, 3039 people completed a questionnaire and were breathalysed as they entered entertainment districts in Queensland, Australia. Of those, 2751 represented people from Brisbane and this data, collected every Thursday night to Sunday morning during the warm months, was analysed. RESULTS: More than 79% of people reported to preload and 71% returned a BAC greater than zero, both with little difference between the genders. Of preloaders, the mean BAC was 0.071, with 'to socialise with friends' being the primary reason given for preloading. Increasing preloading BAC was related to increasing risk taking and antisocial behaviours, as well as alcohol abuse and dependence. Older people entering entertainment districts had more accurate estimates of their BAC, yet 20% of our sample did not understand how the BAC system worked. Conducting the research was associated with a higher access rate to police and a lower arrest rate in the areas of data collection in comparison to the same nights 1year earlier. CONCLUSION: Preloading is widespread and involves moderate to heavy drinking in the Australian population visiting entertainment districts. Any interventions to curb drinking behaviours and reduce violence in night time entertainment districts need to involve approaches aimed at cultural phenomena, such as preloading behaviours.

A meta-analytic review of overgeneral memory: The role of trauma history, mood, and the presence of posttraumatic stress disorder.

A number of studies suggest that a history of trauma, depression, and posttraumatic stress disorder (PTSD) are associated with autobiographical memory deficits, notably overgeneral memory (OGM). However, whether there are any group differences in the nature and magnitude of OGM has not been evaluated. Thus, a meta-analysis was conducted to quantify group differences in OGM. The effect sizes were pooled from studies examining the effect on OGM from a history of trauma (e.g., childhood sexual abuse), and the presence of PTSD or current depression (e.g., major depressive disorder). Using multiple search engines, 13 trauma studies and 12 depression studies were included in this review. A depression effect was observed on OGM with a large effect size, and was more evident by the lack of specific memories, especially to positive cues. An effect of trauma history on OGM was observed with a medium effect size, and this was most evident by the presence of overgeneral responses to negative cues. The results also suggested an amplified memory deficit in the presence of PTSD. That is, the effect sizes of OGM among individuals with PTSD were very large and relatively equal across different types of OGM. Future studies that directly compare the differences of OGM among 4 samples (i.e., controls, current depression without trauma history, trauma history without depression, and trauma history and depression) would be warranted to verify the current findings.

Subjective appraisal of threat (criterion A2) as a predictor of distress in childbearing women.

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, has removed criterion A2 from the diagnosis of posttraumatic stress disorder. The current study aimed to assess the claim that criterion A2 has low use in predicting distress, while addressing the shortcomings of previous research looking at criteria A1 and A2. Data from a longitudinal, prospective study was used, with 933 women having been assessed at four time points both prebirth and postbirth. In our sample of women, model comparisons suggest that criterion A2 should be reintroduced into the diagnostic criteria as it provides a better indicator of who goes on to have problems after giving birth than criterion A1 on its own. There is also evidence that this subjective reaction to event confrontation (A2) should include anger, shame, and guilt.

Predicting posttraumatic stress disorder after childbirth.

OBJECTIVE: around 50% of women report symptoms that indicate some aspect of their childbirth experience was 'traumatic', and at least 3.1% meet diagnosis for PTSD six months post partum. Here we aimed to conduct a prospective longitudinal study and examine predictors of birth-related trauma - predictors that included a range of pre-event factors - as a first step in the creation of a screening questionnaire. METHOD: of the 933 women who completed an assessment in their third trimester, 866 were followed-up at four to six week post partum. Two canonical discriminant function analyses were conducted to ascertain factors associated with experiencing birth as traumatic and, of the women who found the birth traumatic, which factors were associated with those who developed PTSD. FINDINGS: a mix of 16 pre-birth predictor variables and event-specific predictor variables distinguished women who reported symptoms consistent with trauma from those who did not. Fourteen predictor variables distinguished women who went on to develop PTSD from those who did not. CONCLUSIONS: anxiety sensitivity to possible birthing problems, breached birthing expectations, and severity of any actual birth problem, predicted those who found the birth traumatic. Prior trauma was the single most important predictive factor of PTSD. Evaluating the utility of brief, cost-effective, and accurate screening for women at risk of developing birth-related PTSD is suggested.

Childbirth and criteria for traumatic events.

OBJECTIVE: for some women childbirth is physically and psychologically traumatic and meets Criterion A1 (threat) and A2 (intense emotional response) for Posttraumatic Stress Disorder of the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV).This study differentiates Criterion A1 and A2 to explore their individual relationship to prevalence rates for posttraumatic stress, each other, and associated factors for childbirth trauma. DESIGN AND SETTING: women were recruited at three hospitals from October 2008 to October 2009. Questionnaires were completed at recruitment and at 14 days post partum. PARTICIPANTS: women in the third trimester of pregnancy (n=890) were recruited by a research midwife while waiting for their antenatal clinic appointment. Participants were over 17 years of age, expected to give birth to a live infant, not undergoing psychological treatment, and able to complete questionnaires in English. FINDINGS: this study found 14.3% of women met criteria for a traumatic childbirth. When the condition of A2 was removed, the prevalence rate doubled to 29.4%. Approximately half the women who perceived threat in childbirth did not have an intense negative emotional response. Predictors of finding childbirth traumatic were pre-existing psychiatric morbidity, being a first time mother and experiencing an emergency caesarean section. KEY CONCLUSIONS: the fear response is an important diagnostic criterion for assessing psychologically traumatic childbirth. The identification of risk factors may inform maternity service delivery to prevent traumatic birth and postpartum approaches to care to address long-term negative consequences. IMPLICATIONS FOR PRACTICE: prevention and treatment of traumatic childbirth are improved through knowledge of potential risk factors and understanding the woman's subjective experience.