There are several limitations to this research. First, the study design does not allow for the definitive determination of a causal relationship -we can only report observed associations. Second, in each setting, the women recruited represented a convenience sample from one hospital in one city, minimizing the ability to generalize based upon our findings. Third, we created our matched sets based on three variables we believed were most important to control for at the outset: maternal age, gestational age, and number of previous pregnancies. Given the one child policy in China, we did not match on number of previous deliveries -as that would have eliminated all but the nulliparous women in Ghana and the U.S. and reduced our sample size to an untenably low level. However, upon analysis it was discovered that the number of previous deliveries was significantly different across countries. In China, women were more likely to have had a previous pregnancy that did not result in a delivery. Whether these were induced or spontaneous terminations is not known, although previous research indicates that more than half of women in China have had at least one abortion. [29] It is possible that Chinese women who have had the same number of pregnancies as their African and North American counterparts but have not had as many deliveries are in some way inherently different. Our univariate analysis did indicate that number of deliveries was associated with overall LOT-R scores (p = .004), but this significance was not sustainable in the multivariate logistic regression model.