Debriefing interventions for the prevention of psychological trauma in women following childbirth

Association of Postpartum Mental Illness Diagnoses with Severe Maternal Morbidity

Background: This study aimed to determine whether birthing people who experience severe maternal morbidity (SMM) are more likely to be diagnosed with a postpartum mental illness. Materials and Methods: Using the Massachusetts All Payer Claims Database, this study used modified Poisson regression analysis to assess the association of SMM with mental illness diagnosis during the postpartum year, accounting for prenatal mental illness diagnoses and other patient characteristics. Results: There were 128,161 deliveries identified, with 55.0% covered by Medicaid. Of these, 3.1% experienced SMM during pregnancy and/or delivery hospitalization, and 20.1% had a mental illness diagnosis within 1 year postpartum. In adjusted regression analyses, individuals with SMM had a 10.6% increased risk of having any mental illness diagnosis compared to individuals without SMM, primarily due to an increased risk of a depression or post-traumatic stress disorder diagnosis among people with SMM than those without SMM. Conclusions: Individuals who experienced SMM had a higher risk of a mental illness diagnosis in the postpartum year. Given increases in SMM in the United States in recent decades, policies to mitigate mental health sequelae of SMM are urgently needed.

Facilitating positive birth experience when preferences are not met: A qualitative analysis

INTRODUCTION

High-quality health systems rely on care that centers on patient preferences. Realization of patient preferences can improve the birth experience. However, in the dynamic setting of birth, birth preferences can diverge from what is medically indicated. Through studying women and birthing peoples' experiences of unplanned labor procedures, we aimed to identify ways in which practitioners can support women and birthing people through unexpected or unwanted aspects of their delivery. Specifically, we focused on labor induction.

METHODS

In one large US academic center, women and birthing people participated in prenatal and postpartum surveys regarding their desires, expectations, and experiences of labor induction. From April to November 2021, participants were eligible if they showed discordance between having labor induction and whether it was initially wanted or expected. Interviews focused on attitudes toward birth preferences and outcomes, with attention to discordances. We analyzed interviews through a modified grounded theory approach.

RESULTS

Of 22 participants, our sample was predominantly white (91%). Participants in this sample reported discordance between wanting and experiencing (73%) and/or expecting and experiencing (54%) an induction. We identified two themes: "Discordance without mitigation is perceived as a negative experience" and "Practitioner interaction can buffer against negative experience" which includes three ways in which participants prefer support in instances of discordance: preparation, communication, and care and comfort. These methods of support foster patient autonomy and can lead to positive patient experiences.

CONCLUSIONS

While medical systems should work to support patient preferences, our results suggest that patients can still have positive birth experiences, even when preferences are not fulfilled. Early practitioner preparation, positive communication, and responsive care and comfort may help to improve patient birth experience when challenges arise.

Careful considerations for the treatment of posttraumatic stress disorder during and following pregnancy

INTRODUCTION

The focus on perinatal mental health has expanded recently, though there is less research on post-traumatic stress disorder (PTSD). Therefore, a review of the literature was undertaken and coupled with expert clinical insights to discuss current clinical practice recommendations for PTSD in the perinatal period.

AREAS COVERED

This review covers considerations for the assessment, prevention, and treatment of PTSD during the perinatal period. Within these sections, evidence-based and promising practices are outlined. Extra attention is afforded to treatment, which includes considerations from both psychotherapeutic and psychopharmacological perspectives. This review closes with coverage of three important and related areas of consideration, including bereavement, intimate partner violence, and childhood sexual abuse.

EXPERT OPINION

Psychotherapeutic interventions for PTSD during pregnancy are limited, and no strong recommendations can be supported at this time while evidence points toward the effectiveness of cognitive behavioral therapies and eye movement desensitization therapy as first-line treatments postpartum though research evidence is also limited. Research on psychopharmacological interventions is similarly scarce, though selective serotonin reuptake inhibitors may be beneficial. Clinicians should also be mindful of additional considerations that may be needed for the treatment of PTSD in the context of bereavement, intimate partner violence, and history of sexual violence.

Effect of cognitive behavior therapy training and psychological nursing on the midwifery process in the delivery room

BACKGROUND

The severe physical and psychological impact of pain on the physical and mental health of women during labor leads to increased risks and complications during childbirth, presenting a major public health concern. Some studies have shown that cognitive behavioral therapy (CBT) has a positive effect on maternal psychology during delivery, reducing stress and shortening labor time. Thus, CBT training for mothers and delivery room staff may be beneficial in minimizing complications and adverse effects during natural birth.

AIM

To investigate the clinical effects of CBT training and psychological care during delivery, and their therapeutic effects on women in labor.

METHODS

This study used a retrospective analysis and included 140 mothers admitted to the maternity ward between January 2021 and January 2023. The study subjects were randomized into two groups: control (n = 70) and observation (n = 70). Routine care, CBT training, and psychological care were provided to mothers in both groups. Psychological status scores, delivery time, and satisfaction with care pre- and post-delivery were compared, and the incidence of complications after receiving care was analyzed between the two groups.

RESULTS

Although the psychological state of both groups improved significantly in the late stages of labor, the psychological state scores of the mothers in the observation group were significantly lower than those of the mothers in the control group (P < 0.05). The duration of labor and incidence of complications in the observation group were significantly lower than those in the control group (P < 0.05). The mothers in the observation group were significantly more satisfied with nursing care during the course of labor than those in the control group (P < 0.05).

CONCLUSION

CBT training and psychological care for mothers in the midwifery process can effectively improve anxiety and depression, shorten labor duration, reduce postnatal complications, and improve nursing satisfaction and nurse-patient relationships. Its clinical application is effective and has popularization value, providing a new way to protect maternal mental health.

The effect of continuous intrapartum supportive care on maternal mental health: a randomized controlled trial

Supportive care during labor is the primary role of intrapartum nurses and midwives and provides comfort for women allowing them to have a positive experience. It is argued that supportive care during labor reduces fear and resultant side effects. However, evidence for different parameters of mental health is insufficient. The aim of this study was to evaluate the effect of continuous intrapartum supportive care on the fear of childbirth, perceived control and support at birth, birth trauma and maternal attachment. This is a randomized controlled study with an intervention group and a control group. The intervention group included 40 women receiving continuous intrapartum supportive care and the control group included 40 women receiving routine care. Thirty women in the intervention group and 29 women in the control group completed the study. No significant differences were detected between the two groups at baseline (p > .05). Continuous intrapartum supportive care significantly decreased fear of birth and birth trauma, and significantly increased perceived intrapartum control and support and postpartum maternal attachment (p < .01). Results from this evidence-based study suggest that continuous intrapartum supportive care could protect and maintain perinatal mental health.

Single-session visuospatial task procedure to prevent childbirth-related posttraumatic stress disorder: a multicentre double-blind randomised controlled trial

Preventive evidence-based interventions for childbirth-related posttraumatic stress disorder (CB-PTSD) are lacking. Yet, 18.5% of women develop CB-PTSD symptoms following an unplanned caesarean section (UCS). This two-arm, multicentre, double-blind superiority trial tested the efficacy of an early single-session intervention including a visuospatial task on the prevention of maternal CB-PTSD symptoms. The intervention was delivered by trained maternity clinicians. Shortly after UCS, women were included if they gave birth to a live baby, provided consent, and perceived their childbirth as traumatic. Participants were randomly assigned to the intervention or attention-placebo group (allocation ratio 1:1). Assessments were done at birth, six weeks, and six months postpartum. Group differences in maternal CB-PTSD symptoms at six weeks (primary outcomes) and six months postpartum (secondary outcomes) were assessed with the self-report PTSD Checklist for DSM-5 (PCL-5) and by blinded research assessors with the Clinician-administered PTSD scale for DSM-5 (CAPS-5). Analysis was by intention-to-treat. The trial was prospectively registered (ClinicalTrials.gov, NCT03576586). Of the 2068 women assessed for eligibility, 166 were eligible and 146 were randomly assigned to the intervention (n = 74) or attention-placebo control group (n = 72). For the PCL-5, at six weeks, a marginally significant intervention effect was found on the total PCL-5 PTSD symptom count (β = -0.43, S.E. = 0.23, z = -1.88, p < 0.06), and on the intrusions (β = -0.73, S.E. = 0.38, z = -1.94, p < 0.0525) and arousal (β = -0.55, S.E. = 0.29, z = -1.92, p < 0.0552) clusters. At six months, a significant intervention effect on the total PCL-5 PTSD symptom count (β = -0.65, S.E. = 0.32, z = -2.04, p = 0.041, 95%CI[-1.27, -0.03]), on alterations in cognition and mood (β = -0.85, S.E. = 0.27, z = -3.15, p = 0.0016) and arousal (β = -0.56, S.E. = 0.26, z = -2.19, p < 0.0289, 95%CI[-1.07, -0.06]) clusters appeared. No group differences on the CAPS-5 emerged. Results provide evidence that this brief, single-session intervention carried out by trained clinicians can prevent the development of CB-PTSD symptoms up to six months postpartum.

A Systematic Review of Interventions for Prevention and Treatment of Post-Traumatic Stress Disorder Following Childbirth

Objective

Postpartum women can develop post-traumatic stress disorder (PTSD) in response to complicated, traumatic childbirth; prevalence of these events remains high in the U.S. Currently, there is no recommended treatment approach in routine peripartum care for preventing maternal childbirth-related PTSD (CB-PTSD) and lessening its severity. Here, we provide a systematic review of available clinical trials testing interventions for the prevention and indication of CB-PTSD.

Data Sources

We conducted a systematic review of PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, and Scopus through December 2022 to identify clinical trials involving CB-PTSD prevention and treatment.

Study Eligibility Criteria

Trials were included if they were interventional, evaluated CB-PTSD preventive strategies or treatments, and reported outcomes assessing CB-PTSD symptoms. Duplicate studies, case reports, protocols, active clinical trials, and studies of CB-PTSD following stillbirth were excluded.

Study Appraisal and Synthesis Methods

Two independent coders evaluated trials using a modified Downs and Black methodological quality assessment checklist. Sample characteristics and related intervention information were extracted via an Excel-based form.

Results

A total of 33 studies, including 25 randomized controlled trials (RCTs) and 8 non-RCTs, were included. Trial quality ranged from Poor to Excellent. Trials tested psychological therapies most often delivered as secondary prevention against CB-PTSD onset (n=21); some examined primary (n=3) and tertiary (n=9) therapies. Positive treatment effects were found for early interventions employing conventional trauma-focused therapies, psychological counseling, and mother-infant dyadic focused strategies. Therapies' utility to aid women with severe acute traumatic stress symptoms or reduce incidence of CB-PTSD diagnosis is unclear, as is whether they are effective as tertiary intervention. Educational birth plan-focused interventions during pregnancy may improve maternal health outcomes, but studies remain scarce.

Conclusions

An array of early psychological therapies delivered in response to traumatic childbirth, rather than universally, in the first postpartum days and weeks, may potentially buffer CB-PTSD development. Rather than one treatment being suitable for all, effective therapy should consider individual-specific factors. As additional RCTs generate critical information and guide recommendations for first-line preventive treatments for CB-PTSD, the psychiatric consequences associated with traumatic childbirth could be lessened.

["Helplessness, Giving up of Any Self-Responsibility and Self-Determination" - a Qualitative Evaluation of Traumatizing Birth Experiences in Relation to Birth Mode]

Background Childbirth is combined with emotional challenges and individual anxiety. Unexpected birth experiences can trigger stress reactions and even post-traumatic stress disorders. Aim of the study The aim of the study was the qualitative evaluation of stressful perceived birth experiences and desired interventions.Methods A content-analytic evaluation of 117 free-text answers was conducted regarding stressful birth experiences and desired interventions using categories and frequencies in relation to birth mode.Findings Five themes emerged from the structured free text analysis: 1) Stressful experiences describing fear concerning the child and separation from the child after an emergency caesarean section; 2) Inadequate communication after an operative vaginal birth and unplanned caesarean section; 3) Feelings of failure and guilt after unplanned birth modes; 4) Helplessness with loss of personal control and the feeling of being at the mercy after an emergency caesarean section; 5) Inadequate support due to the absence of empathy or insufficient care. Expected interventions include immediate debriefing and professional psychological support.Conclusion Women-centered communication during childbirth and debriefing of stressful birth experiences are significant interventions for strengthening maternal well-being and mental health. They can have a positive impact on the development of a healthy mother-child relationship.

Relationship between birth memories and recall and perception of traumatic birth in women in the postpartum one-year period and affecting factors

This study examines the relationship between birth memory and recall and the perception of traumatic birth in women who were a postpartum one-year period and the affecting factors. This descriptive and correlational study was conducted with 285 participants in the pediatric department of a state university medical school. Data were collected using a participant information form, Birth Memories and Recall Questionnaire, and Perception of Traumatic Childbirth Scale. In the study, it was determined that the women had a moderate level of birth memories and recall, and the rate of those with a "high" and "very high" perception of traumatic childbirth was 45.9%. According to path analysis, Birth Memories and Recall Questionnaire score and educational status (primary secondary school) have a positive and significant effect on the perception of traumatic birth. The perception of traumatic birth was a predictor that explained 17.3% of birth memories and recall. Nearly half of the study participants perceived the experience of giving birth as traumatic, and birth memories and recall were at a moderate level. Improving women's perception of education and traumatic birth will contribute to positive birth memories and to create positive emotions when they remember their birth.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-023-04336-3.

The Effectiveness of Interventions for the Prevention or Treatment of Paternal Perinatal Anxiety: A Systematic Review

Background: The worldwide prevalence of paternal perinatal anxiety (PPA) ranges between 3.4% and 25.0% antenatally, and 2.4% and 51.0% postnatally. Experiencing PPA can adversely impact the individual, partners, and infants. Research concerning PPA is lagging and fragmented compared to research for new mothers. Objectives: To establish the effectiveness of prevention or treatment interventions for PPA in adults identifying as male. Data sources: We completed searches of Medline, EMBASE, PsycINFO and Web of Science from inception to 2 December 2021, as well as hand searches of references from relevant papers. Search selection and data extraction: Randomised controlled trials delivering prevention or treatment interventions and reporting anxiety outcomes for new/expectant fathers in the perinatal mental health period were included. Our review follows the PRISMA reporting guidelines. One reviewer independently screened 5170 titles/abstracts; second reviewers screened 50%. Two reviewers independently screened full text, extracted data, and conducted risk of bias assessments. Synthesis: Cochrane's collaboration tool 2 was used to assess quality. Primarily results are synthesised narratively, a post-hoc sub-group analysis was completed on four studies using the same outcome measure. Main results: Twelve of the 5170 studies fulfilled the inclusion criteria. Studies used psychoeducational or practical skills interventions. Interventions mostly involved couple-dyads and three studies assessed PPA as a primary outcome. Included interventions were prevention-based; no treatment interventions were found. Father-only interventions consistently reported a significant reduction of PPA. Conclusions: Systematic searching yielded no treatment interventions, highlighting a substantial gap in the evidence base. Within a limited and heterogenous sample, no studies targeted diagnosed PPA. Evidence suggested father-focused interventions may be effective in preventing PPA, regardless of the intervention delivery mode or intervention content. However, consistency between study design and options within the field are lacking compared to interventions available for mothers.

Using an emotion-focused approach in preventing psychological birth trauma

PURPOSE

This discussion article considers how an emotion-focused approach can be adopted to prevent psychological birth trauma and to optimize perinatal wellbeing for women and their families.

CONCLUSION

Emotion-focused approaches have a different perspective when compared to other classic psychotherapy methods. This approach may help women to resolve the negative impacts of psychological birth trauma; to prevent posttraumatic stress disorder onset; to lead to better results for mother and baby well-being; and may be cost effective.

PRACTICE IMPLICATIONS

Mental health nurses/midwives should receive education about emotion-focused approaches in addition to gaining competence in basic counseling skills so that they can utilize these approaches with women.

Essential components of postnatal care - a systematic literature review and development of signal functions to guide monitoring and evaluation

BACKGROUND

Postnatal Care (PNC) is one of the healthcare-packages in the continuum of care for mothers and children that needs to be in place to reduce global maternal and perinatal mortality and morbidity. We sought to identify the essential components of PNC and develop signal functions to reflect these which can be used for the monitoring and evaluation of availability and quality of PNC.

METHODS

Systematic review of the literature using MESH headings for databases (Cinahl, Cochrane, Global Health, Medline, PubMed, and Web of Science). Papers and reports on content of PNC published from 2000-2020 were included. Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders.

RESULTS

Forty-Eight papers and reports are included in the systematic review from which 22 essential components of PNC were extracted and used to develop 14 signal functions. Signal functions are used in obstetrics to denote a list of interventions that address major causes of maternal and perinatal morbidity or mortality. For each signal function we identified the equipment, medication and consumables required for implementation. The prevention and management of infectious diseases (malaria, HIV, tuberculosis) are considered essential components of routine PNC depending on population disease burden or whether the population is considered at risk. Screening and management of pre-eclampsia, maternal anaemia and mental health are recommended universally. Promotion of and support of exclusive breastfeeding and uptake of a modern contraceptive method are also considered essential components of PNC. For the new-born baby, cord care, monitoring of growth and development, screening for congenital disease and commencing vaccinations are considered essential signal functions. Screening for gender-based violence (GBV) including intimate partner- violence (IPV) is recommended when counselling can be provided and/or a referral pathway is in place. Debriefing following birth (complicated or un-complicated) was agreed through consensus-building as an important component of PNC.

CONCLUSIONS

Signal functions were developed which can be used for monitoring and evaluation of content and quality of PNC. Country adaptation and validation is recommended and further work is needed to examine if the proposed signal functions can serve as a useful monitoring and evaluation tool.

TRIAL REGISTRATION

The systematic review protocol was registered: PROSPERO 2018 CRD42018107054 .

Subjective Birth Experience Predicts Mother–Infant Bonding Difficulties in Women With Mental Disorders

Background

The subjective experience of giving birth to a child varies considerably depending on psychological, medical, situational, relational, and other individual characteristics. In turn, it may have an impact on postpartum maternal mental health and family relationships, such as mother–infant bonding. The objective of the study was to evaluate the relevance of the subjective birth experience (SBE) for mother–infant bonding difficulties (BD) in women with mental disorders.

Methods

This study used data from N = 141 mothers who were treated for postpartum mental disorders in the mother–baby day unit of the Psychosomatic University Clinic in Dresden, Germany. Patients' mental status at admission and discharge was routinely examined using a diagnostic interview (SCID I) and standard psychometric questionnaires (e.g., EPDS, BSI, PBQ). Both, the SBE (assessed by Salmon's Item List, SIL) as well as medical complications (MC) were assessed retrospectively by self-report. The predictive value of SBE, MC, as well as psychopathological symptoms for mother–infant BD were evaluated using logistic regression analyses.

Results

About half of this clinical sample (47.2%) reported a negative SBE; 56.8% of all mothers presented with severe mother–infant BD toward the baby. Mothers with BD showed not only significantly more depressiveness (EPDS: M = 16.6 ± 5.6 vs. 14.4 ± 6.2^*), anxiety (STAI: M = 57.2 ± 10.6 vs. 51.4 ± 10.6^***), and general psychopathology (BSI-GSI: M = 1.4 ± 0.7 vs. 1.1 ± 0.6^**) compared to women without BD, but also a significantly more negative SBE (SIL: M = 79.3 ± 16.2 vs. 61.3 ± 22.9^***). Moreover, the SBE was the most powerful predictor for BD in univariate and multiple logistic regression analyses [OR = 0.96^*** (95% CI 0.94–0.98) vs. OR = 0.96^** (95% CI 0.93–0.98)], even when univariate significant predictors (e.g., current psychopathology and MC during birth) were controlled.

Conclusions

A negative SBE is strongly associated with mother–infant bonding in patients with postpartum mental disorders. It needs to get targeted within postpartum treatment, preferably in settings including both mother and child, to improve distorted mother–infant bonding processes and prevent long-term risks for the newborn. Furthermore, the results highlight the importance of focusing on the specific needs of vulnerable women prior to and during birth (e.g., emotional safety, good communication, and support) as well as individual factors that might be predictive for a negative SBE.

Depression, anxiety and posttraumatic stress disorder six months following preeclampsia and normotensive pregnancy: a P4 study

Background

Mental health is an integral part of overall health. Mental health disorders following childbirth are common and poor maternal mental health has consequences for both the mother and her infant. Preeclampsia is also relatively common in pregnancy but there is little known about the intersection between these two important conditions. Gaining a better understanding of the psychological consequences following preeclampsia is important, especially the link with depression, anxiety and posttraumatic stress disorder. If women who experience preeclampsia are recognised as being at increased risk of poor mental health, targeted screening in the postpartum period should be implemented.

Aims

To describe the prevalence and symptom severity of depression, anxiety and posttraumatic stress disorder at six months postpartum in women, who had a diagnosis of preeclampsia, compared to those who had normal blood pressure in pregnancy.

Methods

The mental health component of the prospective cohort study, the Postpartum, Physiology, Psychology and Paediatric follow-up study (P4 Study) was used. Women diagnosed with preeclampsia (n = 90) and those who were normotensive during pregnancy (n = 302) completed the Edinburgh Postnatal Depression Scale, General Anxiety Disorder Scale, and the Posttraumatic Stress Diagnostic Scale or Posttraumatic Stress Diagnostic Sclae-5 at six months postpartum.

Results

At six months postpartum, depressive scores were similar in both groups but a higher proportion of women from the preeclampsia group scored above the threshold for depression (2% v 7% p = 0.04). There were no differences between the groups in the prevalence or severity of anxiety or PTSD. However, more women in the preeclampsia group reported their birth experience as a traumatic event (1% vs 7%, p = 0.01). On correlation testing and modelling, booking Edinburgh Postnatal Depression Scale score, any mental health history, experiencing birth as traumatic and the General Anxiety Disorder Scale score were independent predictors of postpartum Edinburgh Postnatal Depression Scale scores.

Conclusion

The postpartum clinical care of women with preeclampsia often focusses on the immediate physical health issues, but these women may also benefit from mental health screening. Targeted screening of preeclamptic women in the postpartum period may lead to more timely referral and initiation of treatment.

Trial registration

Retrospectively registered on 18/11/2013 with the Australian and New Zealand Clinical Trials Registry. Registration Number: ACTRN12613001260718.

Women's experiences and perceptions of women-centered care and respectful care during facility-based childbirth: A meta-synthesis

AIM

The World Health Organization has recommended intrapartum care for a positive childbirth experience through respectful care based on women-centered care. This study aimed to explore women's experiences of facility-based childbirth to gain insights into their perceptions of women-centered care, including humanized childbirth and respectful maternity care during intrapartum care.

METHODS

Used the Joanna Briggs Institute method as the framework for this meta-synthesis, we searched the PubMed, EMBASE, CINAHL, PsycINFO, and LILCAS databases, and included qualitative studies and interviews of women's experiences and perceptions of women-centered care during facility-based childbirth published from 1990 to 2020 in English. Study quality was assessed using the Critical Appraisal Skills Programme checklist. NVivo software was used for data extraction and synthesis.

RESULTS

There were 22 studies from 19 countries that met the established inclusion criteria. Five categories of experiences of facility-based childbirth and perceptions of women-centered care from the synthesized voices of women were generated: (i) value of women through childbirth; (ii) overwhelmed by unpleasant childbearing experiences; (iii) a sense of being respected and valued; (iv) a sense of being disrespected and abused; and (v) inadequate systems and resources. Our meta-synthesis indicated that respectful and helpful interaction between women and healthcare providers produced positive perceptions among women.

CONCLUSIONS

This study emphasizes the importance of respectful interactions and intrapersonal experiences. Strong systems and positive environments lead to positive interactions between women and healthcare providers. Future studies need to consider cultural and economic differences in women-centered care and respectful care for childbirth in different contexts.

Early psychological interventions for prevention and treatment of post-traumatic stress disorder (PTSD) and post-traumatic stress symptoms in post-partum women: A systematic review and meta-analysis

Background

Pre-term or full-term childbirth can be experienced as physically or psychologically traumatic. Cumulative and trans-generational effects of traumatic stress on both psychological and physical health indicate the ethical requirement to investigate appropriate preventative treatment for stress symptoms in women following a routine traumatic experience such as childbirth.

Objective

The objective of this review was to investigate the effectiveness of early psychological interventions in reducing or preventing post-traumatic stress symptoms and post-traumatic stress disorder in post-partum women within twelve weeks of a traumatic birth.

Methods

Randomised controlled trials and pilot studies of psychological interventions preventing or reducing post-traumatic stress symptoms or PTSD, that included women who had experienced a traumatic birth, were identified in a search of Cochrane Central Register of Randomised Controlled Trials, MEDLINE, Embase, Psychinfo, PILOTS, CINAHL and Proquest Dissertations databases. One author performed database searches, verified results with a subject librarian, extracted study details and data. Five authors appraised extracted data and agreed upon risk of bias. Analysis was completed with Rev Man 5 software and quality of findings were rated according to Grading of Recommendation, Assessment, Development, and Evaluation.

Results

Eleven studies were identified that evaluated the effectiveness of a range of early psychological interventions. There was firm evidence to suggest that midwifery or clinician led early psychological interventions administered within 72 hours following traumatic childbirth are more effective than usual care in reducing traumatic stress symptoms in women at 4–6 weeks. Further studies of high methodological quality that include longer follow up of 6–12 months are required in order to substantiate the evidence of the effectiveness of specific face to face and online early psychological intervention modalities in preventing the effects of stress symptoms and PTSD in women following a traumatic birth before introduction to routine care and practice.

Prospero registration

CRD42020202576, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=202576

Early discharge from hospital after birth:How Norwegian parents experience postnatal home visits by midwives - A qualitative study

BACKGROUND

According to the WHO, the quality of care is not conditioned by the length of stay at the postnatal ward. As long as the postnatal care provided is of high quality, it could be better for the family to stay in their home.

AIM

Firstly, to examine parents' experiences of early discharge and home visits by the postnatal ward midwife, in cases where the mother and baby have been discharged within 24 h after birth. Secondly, to examine participants' motivation for opting for early discharge from the hospital.

METHODS

10 individual interviews were conducted, including five where both parents were present. The interviews were carried out 4-12 weeks after birth. The data were analysed using systematic text condensation.

RESULTS

The choice of early discharge was influenced by external factors like a wish to be together as a family while receiving sufficient support from both family and midwife. Internal factors, like previous experience, were also significant. The presence and attitude of the midwife, both in professional and practical terms, affected how the parents perceived postnatal care. Home visits from the midwife also affected the parents' feeling of security.

CONCLUSION

An offer of home visits from the midwife of the postnatal ward enables parents who wish to leave the hospital shortly after birth to receive the necessary care and support in the early postnatal period. This offer is suitable for healthy women who have given birth to a healthy baby and wish to return home not long after birth.

Policy, service, and training provision for women following a traumatic birth: an international knowledge mapping exercise

Background

High numbers of women experience a traumatic birth, which can lead to childbirth-related post-traumatic stress disorder (CB-PTSD) onset, and negative and pervasive impacts for women, infants, and families. Policies, suitable service provision, and training are needed to identify and treat psychological morbidity following a traumatic birth experience, but currently there is little insight into whether and what is provided in different contexts. The aim of this knowledge mapping exercise was to map policy, service and training provision for women following a traumatic birth experience in different European countries.

Methods

A survey was distributed as part of the COST Action “Perinatal mental health and birth-related trauma: Maximizing best practice and optimal outcomes”. Questions were designed to capture country level data; care provision (i.e., national policies or guidelines for the screening, treatment and/or prevention of a traumatic birth, service provision), and nationally mandated pre-registration and post-registration training for maternity professionals.

Results

Eighteen countries participated. Only one country (the Netherlands) had national policies regarding the screening, treatment, and prevention of a traumatic birth experience/CB-PTSD. Service provision was provided formally in six countries (33%), and informally in the majority (78%). In almost all countries (89%), women could be referred to specialist perinatal or mental health services. Services tended to be provided by midwives, although some multidisciplinary practice was apparent. Seven (39%) of the countries offered ‘a few hours’ professional/pre-registration training, but none offered nationally mandated post-registration training.

Conclusions

A traumatic birth experience is a key public health concern. Evidence highlights important gaps regarding formalized care provision and training for care providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07238-x.

Lived experiences of patients with placenta accreta spectrum in Utah: a qualitative study of semi-structured interviews

OBJECTIVE

To describe the lived experience of patients undergoing diagnosis and treatment of placenta accreta spectrum (PAS).

DESIGN

Qualitative study of semi-structured interviews. A content analysis was used to analyse interview data using a consistent set of codes to designate data segments that contain similar material. Codes were analysed and grouped based on thematic similarities. Thematic results were systematically reviewed, verified and audited to address trustworthiness and rigour of the data and analysis.

SETTING

A single PAS programme in Utah, USA, from 2017 to 2020.

PARTICIPANTS

Patients with PAS during the study period were eligible. Those experiencing fetal demise or termination were excluded. Of 25 patients contacted at random, 17 agreed to participate in interviews. Those included were predominantly non-Hispanic white, highly parous, with average age of 34.7 years.

RESULTS

The lived experiences of patients with PAS emerged across the time continuum from diagnosis, pregnancy, birth, to postpartum care and recovery. Themes common across the care continuum were: the emotional burden of diagnosis and management; fear and uncertainty related to health outcomes; and lack of autonomy and medical helplessness related to medical decision-making. Many patients experienced birth-related trauma, mourned the loss of future fertility and were dissatisfied with the lack of options for treatment for this serious pregnancy complication.

CONCLUSIONS

Patients undergoing diagnosis and treatment for PAS often experienced care that conflicted with their goals for pregnancy and birth. Clinical care for PAS would benefit from interventions aiming to engage patients and providers in shared decision-making and systems designed to address the social, psychological and emotional needs of patients with PAS.

Perspectives on barriers and facilitators to mental health support after a traumatic birth among a sample of primarily White and privately insured patients

OBJECTIVE

To elicit the perspectives of individuals with a traumatic birth experience on barriers and facilitators to receiving mental health support in the postpartum period.

METHODS

Individuals who experienced a traumatic birth within the last three years (n = 32) completed semi-structured phone interviews about their birth and postpartum experience. The Post-traumatic Stress Disorder Checklist for DSM-V (PCL-5), Patient Health Questionnaire (PHQ-8), and Generalized Anxiety Disorder scale (GAD-7) were administered. Qualitative data was analyzed using a modified grounded theory by three independent coders.

RESULTS

Among participants, 34.4% screened positive for PTSD, 18.8% for depression, and 34.4% for anxiety. Participants described multi-level barriers that prevented clinicians from recognizing and supporting patients' postpartum mental health needs; those involved lack of communication, education, and resources. Recommendations from participants included that 1) obstetric professionals should acknowledge birth-related trauma experienced by any individual, 2) providers of multiple disciplines need to be integrated into postpartum care, and 3) mental health support may be needed before the ambulatory postpartum visit.

CONCLUSIONS

There are multi-level barriers towards detecting and responding to individuals' mental health needs after a traumatic birth. Obstetric professionals need to use a trauma-informed approach and proactively assess mental health throughout the postpartum period.

Effects of a Midwife-Coordinated Maternity Care Intervention (ChroPreg) vs. Standard Care in Pregnant Women with Chronic Medical Conditions: Results from a Randomized Controlled Trial

The proportion of childbearing women with pre-existing chronic medical conditions (CMC) is rising. In a randomized controlled trial, we aimed to evaluate the effects of a midwife-coordinated maternity care intervention (ChroPreg) in pregnant women with CMC. The intervention consisted of three main components: (1) Midwife-coordinated and individualized care, (2) Additional ante-and postpartum consultations, and (3) Specialized known midwives. The primary outcome was the total length of hospital stay (LOS). Secondary outcomes were patient-reported outcomes measuring psychological well-being and satisfaction with maternity care, health utilization, and maternal and infant outcomes. A total of 362 women were randomized to the ChroPreg intervention (n = 131) or Standard Care (n = 131). No differences in LOS were found between groups (median 3.0 days, ChroPreg group 0.1% lower LOS, 95% CI −7.8 to 7%, p = 0.97). Women in the ChroPreg group reported being more satisfied with maternity care measured by the Pregnancy and Childbirth Questionnaire (PCQ) compared with the Standard Care group (mean PCQ 104.5 vs. 98.2, mean difference 6.3, 95% CI 3.0–10.0, p < 0.0001). In conclusion, the ChroPreg intervention did not reduce LOS. However, women in the ChroPreg group were more satisfied with maternity care.

The Lausanne Infant Crying Stress Paradigm: Validation of an Early Postpartum Stress Paradigm with Women at Low vs. High Risk of Childbirth-Related Posttraumatic Stress Disorder

Stress reactivity is typically investigated in laboratory settings, which is inadequate for mothers in maternity settings. This study aimed at validating the Lausanne Infant Crying Stress Paradigm (LICSP) as a new psychosocial stress paradigm eliciting psychophysiological stress reactivity in early postpartum mothers (n = 52) and to compare stress reactivity in women at low (n = 28) vs. high risk (n = 24) of childbirth-related posttraumatic stress disorder (CB-PTSD). Stress reactivity was assessed at pre-, peri-, and post-stress levels through salivary cortisol, heart rate variability (high-frequency (HF) power, low-frequency (LF) power, and LF/HF ratio), and perceived stress via a visual analog scale. Significant time effects were observed for all stress reactivity outcomes in the total sample (all p < 0.01). When adjusting for perceived life threat for the infant during childbirth, high-risk mothers reported higher perceived stress (p < 0.001, d = 0.91) and had lower salivary cortisol release (p = 0.023, d = 0.53), lower LF/HF ratio (p < 0.001, d = 0.93), and marginally higher HF power (p = 0.07, d = 0.53) than low-risk women. In conclusion, the LICSP induces subjective stress and autonomic nervous system (ANS) reactivity in maternity settings. High-risk mothers showed higher perceived stress and altered ANS and hypothalamic-pituitary-adrenal reactivity when adjusting for infant life threat. Ultimately, the LICSP could stimulate (CB-)PTSD research.

The Paternal Experience of Fear of Childbirth: An Integrative Review

BACKGROUND

It is estimated that approximately 13% of expectant fathers experience a pathological and debilitating fear of childbirth.

OBJECTIVE

The aim of this integrative review was to examine and synthesise the current body of research relating to paternal experience of fear of childbirth.

METHODS

A systematic literature search of five databases-CINAHL, Cochrane Library, MEDLINE, PsycArticles and PsycInfo-identified seventeen papers. Methodological quality of studies was assessed using the Crowe Critical Appraisal Tool.

RESULTS

Thematic data analysis identified three themes: the focus of fathers' childbirth-related fears, the impact of fear of childbirth on health and wellbeing, and fear of childbirth as a private burden.

DISCUSSION

Fear of childbirth is a significant and distressing experience for expectant fathers who may benefit from an opportunity to express their childbirth-related fears in an environment where they feel validated and supported. Antenatal education is recommended to enhance fathers' childbirth-related self-efficacy to reduce fear of childbirth.

CONCLUSIONS

Fear of childbirth may negatively impact the lives of men and consequently their families. Further investigation into methods and models for identifying and supporting men at risk of or experiencing fear of childbirth is required to improve outcomes for this population of men.

The experiences of childbearing women who tested positive to COVID-19 during the pandemic in northern Italy

Problem

The COVID-19 pandemic has significantly challenged maternity provision internationally. COVID-19 positive women are one of the childbearing groups most impacted by the pandemic due to drastic changes to maternity care pathways put in place.

Background

Some quantitative research was conducted on clinical characteristics of pregnant women with COVID-19 and pregnant women’s concerns and birth expectations during the COVID-19 pandemic, but no qualitative findings on childbearing women’s experiences during the pandemic were published prior to our study.

Aim

To explore childbearing experiences of COVID-19 positive mothers who gave birth in the months of March and April 2020 in a Northern Italy maternity hospital.

Methods

A qualitative interpretive phenomenological approach was undertaken. Audio-recorded semi-structured interviews were conducted with 22 women. Thematic analysis was completed using NVivo software. Ethical approval was obtained from the research site’s Ethics Committee prior to commencing the study.

Findings

The findings include four main themes: 1) coping with unmet expectations; 2) reacting and adapting to the ‘new ordinary’; 3) ‘pandemic relationships’; 4) sharing a traumatic experience with long-lasting emotional impact.

Discussion

The most traumatic elements of women’s experiences were the sudden family separation, self-isolation, transfer to a referral centre, the partner not allowed to be present at birth and limited physical contact with the newborn.

Conclusion

Key elements of good practice including provision of compassionate care, presence of birth companions and transfer to referral centers only for the most severe COVID-19 cases should be considered when drafting maternity care pathways guidelines in view of future pandemic waves.

Health care practitioners' views of the support women, partners, and the couple relationship require for birth trauma: current practice and potential improvements

AIM

To examine health care practitioners' views of the support women, partners, and the couple relationship require when affected by birth trauma, barriers to gaining such support, and potential improvements.

BACKGROUND

Ongoing distress following psychologically traumatic childbirth, also known as birth trauma, can affect women, partners, and the couple relationship. Birth trauma can lead to post traumatic stress symptoms (PTSS) or disorder (PTSD). Whilst there is a clear system of care for a PTSD diagnosis, support for the more prevalent experience of birth trauma is not well-defined.

METHOD

An online survey of health care practitioners' views of the support parents require for birth trauma, barriers to accessing support, and potential improvements. Practitioners were recruited in 2018 and the sample for the results presented in the article ranged from 95 to 110.

RESULTS

Practitioners reported differing needs of support for women, partners, and the couple as a unit. There was correlation between practitioners reporting having the skills and knowledge to support couples and feeling confident in giving support. The support most commonly offered by practitioners to reduce the impact on the couple relationship was listening to the couple. However practitioners perceived the most effective support was referral to a debriefing service. Practitioners observed several barriers to both providing support and parents accessing support, and improvements to birth trauma support were suggested.

CONCLUSIONS

Practitioners indicate that some women, partners, and the couple as a unit require support with birth trauma and that barriers exist to accessing effective support. The support that is currently provided often conflicts with practitioners' perception of what is most effective. Practitioners indicate a need to improve the identification of parents who need support with birth trauma, and more suitable services to support them.

Postnatal consultations with an obstetrician after critical perinatal events: a qualitative study of what women and their partners experience

OBJECTIVE

The objective of this study was to explore women's and their partners' experiences with attending postnatal consultations with an obstetrician after critical perinatal events.

DESIGN

Qualitative interview study. We did semi-structured individual narrative interviews exploring the lived experiences. Interviews were analysed using a phenomenological approach and the thematic analysis was validated by a transdisciplinary group of anthropologists, obstetricians and a midwife.

SETTING

Department of obstetrics at a large hospital in Denmark.

PARTICIPANTS

We did a qualitative study with 17 participants (10 women and 7 partners) who had experienced critical perinatal events.

RESULTS

Five major themes were identified: (1) a need to gain understanding and make sense of the critical perinatal events, (2) a need for relational continuity, (3) the importance of discussing emotional effects as well as physical aspects of occurred events, (4) preparing for future pregnancies and (5) closure of the story.Most of the participants emphasised the importance of knowing the obstetrician undertaking the postnatal consultation. The majority of the participants described a need to discuss the emotional effects of the experience as well as the physical aspects of occurred events. The postnatal consultation served as an approach to obtain a positive closure of their birth story and to feel confident about potential future pregnancies.

CONCLUSIONS

This interview-based study suggests that postnatal consultation with an obstetrician might be an important tool for women and their partners in understanding the course of events during the critical birth experience and in processing it and preparing for future pregnancies. It appears to be important to assign an obstetrician whom they already know and to encourage them to discuss not only physical aspects of what happened but also the emotional effects of the experience.

Can we improve women's experience of operative vaginal birth?

OBJECTIVE

It is well understood that advanced skills are required for operative vaginal delivery to ensure a woman's birth experience is safe, positive and to prevent adverse long term harm. We sought to identify non-technical skills determined by women to enhance experience of operative vaginal delivery by qualitative analysis of interviews conducted during the postpartum period.

DESIGN

A qualitative study using semi structured interviews took place at a University teaching hospital. Sixteen women who had an operative delivery of a term baby underwent a semi structured interview at 6-8 weeks postnatal. The women were asked to reflect on good and bad experiences of their delivery and the interview was recorded verbatim. Thematic coding of data was carried out and then analysed. Women were given the option to review the transcript for respondent validation. The anonymised transcripts were independently coded by two researchers and then compared for consistency of interpretation. The themes that emerged following the final coding were used to identify a framework of behavioural and clinical skills.

RESULTS

We identified several non-technical skills that were important to women's' experience of operative delivery. Professional behaviour and relationships, decision making and communication, preconceptions and preparation for operative birth, teamwork, environment and consent were themes that emerged from women's experiences which can now provide clinicians with a comprehensive behavioural framework for operative vaginal delivery.

CONCLUSION

This illustration of detailed non-technical skills that has been validated by women could be used as part of clinical training and revalidation.

Induction of labor, and physiological and psychological stress responses as expressed by salivary cortisol: a prospective study

PURPOSE

To describe patterns of physiological and psychological stress during induced labor and their correlation to obstetrical and neonatal outcomes.

METHODS

This prospective, observational study included 167 women, with low-risk, singleton pregnancies, who delivered at term, at a tertiary academic center from 2015 through 2018. Among them, 72 (43%) underwent induction and 95 (57%) had spontaneous labor onset. Physiological stress was evaluated by salivary cortisol measurements and emotional stress by questionnaires (visual analogue stress scale 0-10) during latent phase, active phase and full dilation stages of labor, as well as 2 min and 2 h postpartum. Cord blood cortisol and pH were obtained. Stress patterns were compared between parturients who did or did not undergo induction. Modes of delivery, labor and delivery complications, and early neonatal outcomes were compared. Mothers completed the Hospital Anxiety and Depression Scale.

RESULTS

Induced women had lower cortisol concentrations during the latent phase compared to spontaneous onset of labor (p = 0.003), with no differences during active (p = 0.237), full dilation (0.668), 2 min and 2 h after delivery (p = 0.666). Stress scale and Hospital Anxiety and Depression Scale scores were similar between groups. Cord cortisol (p = 0.294), 1-min Apgar score ≤ 7 (p = 0.502) and 5-min Apgar score ≤ 7 (p = 0.37) were similar. All had cord pH > 7.

CONCLUSIONS

Induction does not increase stress during labor. Moreover, it might have a positive effect on reducing cortisol during the latent phase. These findings might reassure women who are concerned about induction of labor.

Postpartum lifestyle interventions among women with pre-eclampsia: a scoping review protocol

INTRODUCTION

Compared to women with normotensive pregnancies, women with a history of pre-eclampsia have a roughly fourfold increased risk of developing chronic arterial hypertension and a twofold increased risk of developing cardiovascular disease (CVD). Lifestyle changes, such as increased physical activity, weight loss, smoking cessation and healthy diet, are effective for CVD prevention in the general population. However, no scoping review or systematic review of postpartum lifestyle interventions among women with pre-eclampsia have, to our best knowledge, been performed. The objective of this scoping review is to provide an overview of the available research literature on postpartum lifestyle interventions to reduce the risk of CVD among women with pre-eclampsia.

METHODS AND ANALYSIS

The protocol is based on the framework outlined by Arksey and O'Malley. Databases to be searched include: PubMed, Embase CINAHL and the JBI Database of Systematic Reviews and Implementation Reports. The search will be performed after the publication of this protocol (estimated to be 1 June 2020) and will be repeated 1 month prior to the submission for publication of the final review (estimated to be 1 January 2021). The review will consider studies that include women in the postpartum period (in particular, but not restricted to, the first 12 months after delivery), with a history of pre-eclampsia. Data will be extracted by two independent reviewers using a data extraction tool including specific details about the population, concept, context, study methods and key findings relevant to the review objective. Any disagreements between the reviewers will be resolved through discussion, or with a third reviewer. The extracted data will be presented in diagrammatic or tabular form that align with the objective of this scoping review. A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the reviews objective and questions.

ETHICS AND DISSEMINATION

Since all data will be obtained from publicly available materials, the proposed scoping review does not require ethical approval. The results will be submitted for publication in an open-access peer-reviewed journal and presented at relevant conferences.

Effects of counseling based on Gamble's approach on psychological birth trauma in primiparous women: a randomized clinical trial

Background: Psychological birth trauma has persistent adverse effects on the performance and health of women during and after childbirth. Therefore, Interventions to prevent and mitigate psychological birth trauma are of paramount importance.Objective: The present study aimed to investigate the effects of counseling based on Gamble's approach on psychological birth trauma in primiparous women.Materials and methods: This randomized clinical trial was conducted on 60 primiparous women referring to the health centers in Mashhad, Iran in 2018. In the intervention group, counseling was provided by an obstetrician based on Gamble's strategy to each participant in three sessions before delivery and one session postpartum. The participants in the control group only received routine prenatal care. Data were collected using demographic and obstetrics characteristics questionnaire and psychological birth trauma questionnaire. The data were analyzed using SPSS, version 21 and chi-square and independent t-test. p-value less than .05 was considered significant.Results: The mean age of the women in the intervention and control groups was 23.3 ± 3.9 and 24.4 ± 4.4, and the mean prenatal age upon delivery was 40.8 ± 5.7 and 39.8 ± 1.2 weeks respectively. The mean score of psychological birth trauma in the intervention (counseling) and control groups was 37.2 ± 10.4 and 47.6 ± 16.3, respectively, which was significantly lower in the intervention group (p = .003).Conclusion: According to the results, counseling based on Gamble's approach could reduce psychological birth trauma in primiparous women. Therefore, this effective, simple, cost-effective, and harmless approach could be employed to reduce intrapartum and postpartum maternal traumas and prevent adverse events for the mother and the newborn.

Improving mental health and physiological stress responses in mothers following traumatic childbirth and in their infants: study protocol for the Swiss TrAumatic biRth Trial (START)

INTRODUCTION

Emergency caesarean section (ECS) qualifies as a psychological trauma, which may result in postnatal post-traumatic stress disorder (PTSD). Maternal PTSD may not only have a significant negative impact on mother-infant interactions, but also on long-term infant development. The partner's mental health may also affect infant development. Evidence-based early interventions to prevent the development of postpartum PTSD in mothers are lacking. Immediately after a traumatic event, memory formation is vulnerable to interference. There is accumulating evidence that a brief behavioural intervention including a visuospatial task may result in a reduction in intrusive memories of the trauma.

METHODS AND ANALYSIS

This study protocol describes a double-blind multicentre randomised controlled phase III trial testing an early brief maternal intervention including the computer game 'Tetris' on intrusive memories of the ECS trauma (≤1 week) and PTSD symptoms (6 weeks, primary outcome) of 144 women following an ECS. The intervention group will carry out a brief behavioural procedure including playing Tetris. The attention-placebo control group will complete a brief written activity log. Both simple cognitive tasks will be completed within the first 6 hours following traumatic childbirth. The intervention is delivered by midwives/nurses in the maternity unit.The primary outcome will be differences in the presence and severity of maternal PTSD symptoms between the intervention and the attention-placebo control group at 6 weeks post partum. Secondary outcomes will be physiological stress and psychological vulnerability, mother-infant interaction and infant developmental outcomes. Other outcomes will be psychological vulnerability and physiological regulation of the partner and their bonding with the infant, as well as the number of intrusive memories of the event.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Human Research Ethics Committee of the Canton de Vaud (study number 2017-02142). Dissemination of results will occur via national and international conferences, in peer-reviewed journals, public conferences and social media.

TRIAL REGISTRATION NUMBER

NCT03576586.

The EMDR Recent Birth Trauma Protocol: a pilot randomised clinical trial after traumatic childbirth

Objective: This pilot study investigated the effectiveness of brief EMDR intervention as compared to treatment-as-usual (TAU) in women with post-partum PTSD symptoms.Design: A pilot randomised controlled trial was conducted to evaluate possible differences between one EMDR session (n = 19) and one TAU session (n = 18) delivered in a maternity ward in the aftermath of childbirth.Main Outcome Measures: The primary outcome measure was the rate of remission of post-partum post-traumatic stress symptoms (i.e. IES-R score <23) in both groups at 6-weeks (T1) and 12-weeks' post-partum (T2). Secondary outcome measures were mother-to-infant bonding, post-partum depressive symptoms, the presence of flashbacks and level of distress.Results: Most of the women improved their post-partum post-traumatic stress symptoms after only one treatment session. EMDR resulted more effective than TAU in reducing the proportion of women with post-partum post-traumatic stress symptoms at 6-weeks' post-partum (78.9% EMDR vs. 39.9% TAU; p = .020). Moreover, women treated with EMDR experienced less flashbacks and distress as compared to TAU. No significant difference was found between treatments on mother-to-infant bonding and post-partum depressive symptoms.Conclusions: These findings, although preliminary, suggest that a brief EMDR intervention could be a viable and promising tool in the early treatment of post-traumatic stress related to traumatic childbirth.

Effect of Brief Cognitive Behavioral Counseling and Debriefing on the Prevention of Post-traumatic Stress Disorder in Traumatic Birth: A Randomized Clinical Trial

OBJECTIVE

Planning to promote the health of mothers in postpartum is important in all countries. This study aimed to determine the effectiveness of two counseling method on prevention of post-traumatic stress after childbirth.

METHODS

In this clinical trial, 193 of mothers who had experienced a traumatic birth were randomly assigned to three groups. Participants were assessed using IES_R questionnaire at 4-6 weeks and 3 months after delivery.

RESULTS

Debriefing and brief cognitive behavioral counseling (CBC) significantly improved the symptoms of postpartum traumatic stress disorder. After 3 months, CBC had a significant effect on the symptoms.

CONCLUSION

Screening of traumatic childbirth, implementation of supportive care, and early counseling prior to the initiation of post-traumatic stress are recommended.

TRIAL REGISTRATION NUMBER

IRCT2015072522396N2. http://en.search.irct.ir/view/24735 .

Does music during labor affect mode of delivery in first labor after epidural anesthesia? A prospective study

KEY MESSAGE

Listening to music during labor increases the likelihood that primiparas will have a spontaneous vaginal delivery.

PURPOSE

To examine the effects of exposure to music during labor on the mode of delivery and parturients' stress levels.

METHODS

This prospective, interventional study included 124 low-risk women who were recruited during latent phase of their first labor after epidural anesthesia. Patients were grouped according to their preference to receive music intervention or not. The music intervention included two subgroups: soft classical music and rhythmic music. We evaluated cortisol levels in saliva as a surrogate for stress level and State-Trait Personality Inventory at enrollment and 1-3 h later in all women who were still in labor. Delivery and perinatal outcomes were collected from electronic medical records. Correlations between the music intervention and maternal and perinatal outcomes were evaluated.

RESULTS

Spontaneous vaginal delivery was significantly more frequent among women listening to music compared to the non-music group (P = 0.035). A trend towards lower rates of cesarean delivery was noted in the music group (P = 0.08), with no difference in instrumental vaginal delivery rates. Stress levels, as measured by questionnaires and by cortisol levels, blood pressure and pulse rate, remained similar throughout the study. No differences were noted between the different genres of music when examining obstetric and perinatal outcomes and stress levels.

CONCLUSION

Listening to music during labor, improves the likelihood of primiparas to have a vaginal delivery regardless of stress level. As this treatment is simple, easy, and harmless to administer, we suggest it may be offered to all patients during labor.

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder

BACKGROUND

The prevention of long-term psychological distress following traumatic events is a major concern. Systematic reviews have suggested that individual psychological debriefing is not an effective intervention at preventing post-traumatic stress disorder (PTSD). Over the past 20 years, other forms of intervention have been developed with the aim of preventing PTSD.

OBJECTIVES

To examine the efficacy of psychological interventions aimed at preventing PTSD in individuals exposed to a traumatic event but not identified as experiencing any specific psychological difficulties, in comparison with control conditions (e.g. usual care, waiting list and no treatment) and other psychological interventions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and ProQuest's Published International Literature On Traumatic Stress (PILOTS) database to 3 March 2018. An earlier search of CENTRAL and the Ovid databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to May 2016). We handsearched reference lists of relevant guidelines, systematic reviews and included study reports. Identified studies were shared with key experts in the field.We conducted an update search (15 March 2019) and placed any new trials in the 'awaiting classification' section. These will be incorporated into the next version of this review, as appropriate.

SELECTION CRITERIA

We searched for randomised controlled trials of any multiple session (two or more sessions) early psychological intervention or treatment designed to prevent symptoms of PTSD. We excluded single session individual/group psychological interventions. Comparator interventions included waiting list/usual care and active control condition. We included studies of adults who experienced a traumatic event which met the criterion A1 according to the Diagnostic and Statistical Manual (DSM-IV) for PTSD.

DATA COLLECTION AND ANALYSIS

We entered data into Review Manager 5 software. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data with a fixed-effect meta-analysis, except where there was heterogeneity, in which case we used a random-effects model. Two review authors independently assessed the included studies for risk of bias and discussed any conflicts with a third review author.

MAIN RESULTS

This is an update of a previous review.We included 27 studies with 3963 participants. The meta-analysis included 21 studies of 2721 participants. Seventeen studies compared multiple session early psychological intervention versus treatment as usual and four studies compared a multiple session early psychological intervention with active control condition.Low-certainty evidence indicated that multiple session early psychological interventions may be more effective than usual care in reducing PTSD diagnosis at three to six months' follow-up (RR 0.62, 95% CI 0.41 to 0.93; I² = 34%; studies = 5; participants = 758). However, there was no statistically significant difference post-treatment (RR 1.06, 95% CI 0.85 to 1.32; I² = 0%; studies = 5; participants = 556; very low-certainty evidence) or at seven to 12 months (RR 0.94, 95% CI 0.20 to 4.49; studies = 1; participants = 132; very low-certainty evidence). Meta-analysis indicated that there was no statistical difference in dropouts compared with usual care (RR 1.34, 95% CI 0.91 to 1.95; I² = 34%; studies = 11; participants = 1154; low-certainty evidence) .At the primary endpoint of three to six months, low-certainty evidence indicated no statistical difference between groups in reducing severity of PTSD (SMD -0.10, 95% CI -0.22 to 0.02; I² = 34%; studies = 15; participants = 1921), depression (SMD -0.04, 95% CI -0.19 to 0.10; I² = 6%; studies = 7; participants = 1009) or anxiety symptoms (SMD -0.05, 95% CI -0.19 to 0.10; I² = 2%; studies = 6; participants = 945).No studies comparing an intervention and active control reported outcomes for PTSD diagnosis. Low-certainty evidence showed that interventions may be associated with a higher dropout rate than active control condition (RR 1.61, 95% CI 1.11 to 2.34; studies = 2; participants = 425). At three to six months, low-certainty evidence indicated no statistical difference between interventions in terms of severity of PTSD symptoms (SMD -0.02, 95% CI -0.31 to 0.26; I² = 43%; studies = 4; participants = 465), depression (SMD 0.04, 95% CI -0.16 to 0.23; I² = 0%; studies = 2; participants = 409), anxiety (SMD 0.00, 95% CI -0.19 to 0.19; I² = 0%; studies = 2; participants = 414) or quality of life (MD -0.03, 95% CI -0.06 to 0.00; studies = 1; participants = 239).None of the included studies reported on adverse events or use of health-related resources.

AUTHORS' CONCLUSIONS

While the review found some beneficial effects of multiple session early psychological interventions in the prevention of PTSD, the certainty of the evidence was low due to the high risk of bias in the included trials. The clear practice implication of this is that, at present, multiple session interventions aimed at everyone exposed to traumatic events cannot be recommended. There are a number of ongoing studies, demonstrating that this is a fast moving field of research. Future updates of this review will integrate the results of these new studies.

Effect of the Sacred Hour on Postnatal Depression in Traumatic Childbirth: a Randomized Controlled Trial

Introduction: the implementation of the baby’s nine instinctive stages as a sacred hour after birth is very effective in starting breastfeeding. About half of newly delivered mothers have reported a traumatic childbirth experience often associated with mental health problems. The present study aimed to examine the effect of the sacred hour on the depression in traumatic childbirths.

Methods: In this clinical trial, 84 mothers who had experienced a traumatic childbirth were randomly allocated into the intervention (n = 42) and control (n = 42) groups. The intervention group received sacred hour (baby’s nine instinctive responses), but the control group received only the routine care. Postnatal depression was evaluated as primary outcome at 2 week, 4-6 week and 3 month intervals after the delivery. The data were analyzed using t test, chi-square test and the repeated measures analysis of variance.

Results: The results showed that the marginal total mean (SD: standard deviation) scores of depression in the intervention and control groups were 7.5 (2.6) and 9.6 (2.6); therefore, the mean difference (95% CI) between the groups (-2.1, (-3.2,-0.95)) was significant.

Conclusion: The implementation of the sacred hour is recommended as a preventive approach to reduce the postnatal depression in women with a traumatic childbirth experience.

Indications for increase in caesarean delivery

BACKGROUND

The increasing caesarean delivery rate worldwide is followed by increased maternal morbidity due to pathological placentation, peripartum hysterectomy and obstetric bleeding. The aim of this study was to investigate the indications for caesarean delivery.

STUDY DESIGN

A retrospective observational study. Data were retrieved from the Swedish Pregnancy Register and obstetric records at a tertiary hospital in Sweden between the early 1990s and 2015.

RESULTS

Caesarean delivery in Sweden increased from 10% in the early 1990s to 17% in 2015 concomitantly with decreased instrumental delivery and increased labour induction. Most planned caesareans at the tertiary hospital were performed on maternal request with a rate increasing from 0.6 to 4.6% of all deliveries (p < 0.001), and 60% of these women reported secondary fear of vaginal delivery. The second most common indication previous uterine scar increased from 1.2 to 2.3% (p < 0.001). Most urgent caesareans in 2015 were carried out because of prolonged labour with the rate increasing from 2.1% to 5.4% of all deliveries (p < 0.001). The second most common indication was imminent fetal asphyxia which increased from 2.4 to 2.6% (p < 0.01).

CONCLUSIONS

The Swedish caesarean delivery rate increased concomitantly with a decrease in instrumental delivery and an increase in labour induction. Most of the planned caesareans were performed on maternal request and most of the urgent caesareans were carried out because of prolonged labour. These findings emphasise the importance of standardised definitions of maternal request and follow-up after a negative birth experience, as well as adequate definitions of prolonged labour and foetal asphyxia to decrease unnecessary caesareans.

Maternal reasons for requesting planned cesarean section in Norway: a qualitative study

Background

Pregnant women who request a cesarean section in the absence of obstetric indication have become a highly debated issue in academic as well as popular literature. In order to find adequate, targeted treatment and preventive strategies, we need a better understanding of this phenomenon. The aim of this study is to provide a qualitative exploration of maternal requests for a planned cesarean section in Norway, in the absence of obstetric indications.

Methods

A descriptive qualitative study was conducted consisting of 17 semi-structured, in-depth interviews with women requesting cesarean section and six focus group discussions with 20 caregivers (nine midwives, 11 obstetricians) working at a university hospital in Norway. Data were analyzed with Systematic Text Condensation, a method for thematic cross-case analysis.

Results

Fear of birth emerged most commonly as a result of a previous traumatic birth experience that prompted a preference for a planned cesarean to avoid a repetition of the trauma. For some women in our study, postnatal care and the puerperal period were their crucial past experiences, and giving birth by planned cesarean was seen as a way to ensure mental rather than physical capability to care for the expected child after birth. Others were under the impression of being at high risk for an emergency C-section, and requesting a planned one was based on their perceived risk. Such perceptions included having a narrow pelvis, hereditary factors or previous birth outcomes. Some primiparas requested a planned cesarean based on a deep-seated fear since their early teens, accompanied by alienation towards the idea of giving birth. Some obstetricians participating in our study also experienced requests that lacked what they regarded as any well-grounded reason or significant fear.

Conclusions

Behind a maternal request for a planned cesarean section are various rationales and life experiences needing carefully targeted attention and health care. Previous births are an important driver; thus, maternally requested cesareans should be regarded partly as an iatrogenic problem.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2250-6) contains supplementary material, which is available to authorized users.

Assessing emotional aspects of midwives' intrapartum care: Development of the emotional availability and responsiveness in intrapartum care scale

BACKGROUND/PROBLEM

Emotional care underpins women's positive experiences during labour andbirth but is under-researched. Applying an attachment theory approach may inform the measurement of emotional aspects of maternity care.

OBJECTIVE

To develop and validate a self - report measure for midwives to assess their emotionally attuned intrapartum care.

METHODS

A staged approach to tool development was followed. Item generation was informed by a critical review of the literature and expert review. Following a pilot test, the draft scale was psychometrically assessed. Principal component analysis with varimax rotation was used to establish construct validity. Cronbach's alpha determined internal reliability. Concurrent validity was tested with the 'empathic concern' and the 'personal distress' subscales on the Interpersonal Reactivity Index. The study was conducted with midwives (n = 705) who are members of the Australian College of Midwives.

FINDINGS

The Cronbach's alpha for the scale was 0.88. Principal component analysis revealed a one- factor solution. Significant but low correlations with Interpersonal Reactivity Index subscales of 'empathic concern' (rho = .256, p <.001) and 'personal distress' (rho = -.249, p<.001) confirmed concurrent validity.

CONCLUSION

The Emotional Availability and Responsiveness in Intrapartum Care Scale appears to be a valid and reliable measure of emotional aspects of midwives' caregiving. An Attachment Theory approach validates women's perspectives and elucidates our understanding of the importance of emotional labour support.

Early psychological intervention following recent trauma: A systematic review and meta-analysis

Background: Post-traumatic stress disorder (PTSD) is a common and debilitating disorder which has a significant impact on the lives of sufferers. A number of early psychological interventions have been developed to try to prevent chronic difficulties. Objective: The objective of this study was to establish the current evidence for the effectiveness of multiple session early psychological interventions aimed at preventing or treating traumatic stress symptoms beginning within three months of trauma exposure. Methods: Randomized controlled trials of early multiple session psychological interventions aimed at preventing or reducing traumatic stress symptoms of individuals exposed to a traumatic event, fulfiling trauma criteria for an ICD or DSM diagnosis of PTSD were identified through a search of the Cochrane Common Mental Disorders Group Clinical Trials Registers database, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO and PILOTS. Two authors independently extracted study details and data and completed risk of bias assessments. Analyses were undertaken using Review Manager software. Quality of findings were rated according to 'Grades of Recommendation, Assessment, Development, and Evaluation' (GRADE) and appraised for clinical importance. Results: Sixty-one studies evaluating a variety of interventions were identified. For individuals exposed to a trauma who were not pre-screened for traumatic stress symptoms there were no clinically important differences between any intervention and usual care. For individuals reporting traumatic stress symptoms we found clinically important evidence of benefits for trauma-focused cognitive-behavioural therapy (CBT-T), cognitive therapy without exposure and eye movement desensitization and reprocessing (EMDR). Differences were greatest for those diagnosed with acute stress disorder (ASD) and PTSD. Conclusions: There is evidence for the effectiveness of several early psychological interventions for individuals with traumatic stress symptoms following trauma exposure, especially for those meeting the diagnostic threshold for ASD or PTSD. Evidence is strongest for trauma-focused CBT.

A longitudinal, multi-centre, superiority, randomized controlled trial of internet-based cognitive behavioural therapy (iCBT) versus treatment-as-usual (TAU) for negative experiences and posttraumatic stress following childbirth: the JUNO study protocol

BACKGROUND

About one-third of women report their childbirth as traumatic and up to 10% have severe traumatic stress responses to birth. The prevalence of Posttraumatic stress disorder following childbirth (PTSD FC) is estimated to 3%. Women with PTSD FC report the same symptoms as other patients with PTSD following other types of trauma. The effect of psychological treatment for women with PTSD FC has only been studied in a few trials. Similarly, studies on treatment needs for women not diagnosed as having PTSD FC but who nevertheless face psychological problems are lacking.

METHODS/DESIGN

Women who rate their overall birth experience as negative on a Likert scale, and/or had an immediate caesarean section and/or a major postpartum haemorrhage are randomized to either internet delivered cognitive behaviour therapy (iCBT) plus treatment as usual (TAU) or TAU. The iCBT is to be delivered in two steps. The first step consists of six weekly modules for both the woman and her partner (if they wish to participate) with minimal therapeutic support. Step 2 consists of eight weekly modules with extended therapeutic support and will be offered to participants whom after step 1 report PTSD FC. Assessments will be made at baseline, 6 weeks, 14 weeks, and at follow-ups at 1, 2, 3 and 4 years after baseline. The primary outcome measures are symptoms of posttraumatic stress and depression. Secondary outcomes are quality of life, parent-child bonding, marital satisfaction, coping strategies, experience regarding the quality of care received, health-related quality of life, number of re-visits to the clinic and number of appointments for counselling during the 4 years' period after the negative childbirth experience, time until the woman gets pregnant again, and the type of birth in the subsequent pregnancy. A health economic evaluation in the form of a cost utility analysis will be conducted.

DISCUSSION

This study protocol describes a randomized controlled trial that will provide information about the effectiveness of iCBT in women with negative experiences, posttraumatic stress, and PTSD FC.

TRIAL REGISTRATION

ISRCTN39318241 . Date for registration 12/01/2017, retrospectively registered.

Quality of Life after an Episode of Severe Maternal Morbidity: Evidence from a Cohort Study in Brazil

OBJECTIVE

To assess quality of life (QOL) in women who experienced a severe maternal morbidity (SMM) event and associated factors, in comparison to those who did not.

STUDY DESIGN

Retrospective cohort study performed at the maternity of the University of Campinas in Brazil, including 801 women with or without SMM, within 6 months to 5 years after delivery. Women were interviewed by phone and data were electronically stored, using the Brazilian version of the SF36 to assess women's self-perception of quality of life. To analyze a possible relationship between SMM and perceived impairment in quality of life, χ2 and Fisher's Exact tests were used. Multiple analysis using Generalized Linear Models was applied to identify factors independently associated with the general health score. The main outcome measures were general and domain-specific SF36 scores on quality of life.

RESULTS

Maternal morbidity conditions were associated with lower scores of patient perceptions of quality of life in the following domains: physical functioning, role-limiting physical, pain, and general health status. A lower level of school education, not having a partner, caesarean section, and history of previous clinical conditions were associated with a worse perception of general health and quality of life.

CONCLUSION

Health professionals should know the association between life conditions, previous chronic health conditions, and SMM for women during prenatal care to beyond 42 weeks postpartum. Longitudinal and interdisciplinary actions should be put into practice to provide healthcare for these women, with special emphasis on the effective reduction in health inequities.

Creating a positive perception of childbirth experience: systematic review and meta-analysis of prenatal and intrapartum interventions

BACKGROUND

A negative experience in childbirth is associated with chronic maternal morbidities. The aim of this systematic review and meta-analysis was to identify currently available successful interventions to create a positive perception of childbirth experience which can prevent psychological birth trauma.

METHODS

Randomized controlled trials of interventions in pregnancy or labour which aimed to improve childbirth experience versus usual care were identified from 1994 to September 2016. Low risk pregnant or childbearing women were chosen as the study population. PEDRO scale and Cochrane risk of bias tool were used for quality assessment. Pooled effect estimates were calculated when more than two studies had similar intervention. If it was not possible to include a study in the meta-analysis, its data were summarized narratively.

RESULTS

After screening of 7832 titles/abstracts, 20 trials including 22,800 participants from 12 countries were included. Successful strategies to create a positive perception of childbirth experience were supporting women during birth (Risk Ratio = 1.35, 95% Confidence Interval: 1.07 to 1.71), intrapartum care with minimal intervention (Risk Ratio = 1.29, 95% Confidence Interval:1.15 to 1.45) and birth preparedness and readiness for complications (Mean Difference = 3.27, 95% Confidence Interval: 0.66 to 5.88). Most of the relaxation and pain relief strategies were not successful to create a positive birth experience (Mean Difference = - 2.64, 95% Confidence Intervention: - 6.80 to 1.52).

CONCLUSION

The most effective strategies to create a positive birth experience are supporting women during birth, intrapartum care with minimal intervention and birth preparedness. This study might be helpful in clinical approaches and designing future studies about prevention of the negative and traumatic birth experiences.

Effectiveness of Trauma-Focused Psychological Therapies for Treating Post-traumatic Stress Disorder Symptoms in Women Following Childbirth: A Systematic Review and Meta-Analysis

Background: Approximately 3% of women in community samples develop posttraumatic stress disorder (PTSD) after childbirth. Higher prevalence rates are reported for high risk samples. Postpartum PTSD can adversely affect women's wellbeing, mother-infant relationships and child development. This study aims to examine the effectiveness of trauma-focused psychological interventions (TFPT), for postnatal women. Methods: We conducted a systematic review and meta-analysis including all clinical trials which reported post-traumatic stress symptoms for both the intervention and control groups or at least two time-points, pre- and post-intervention. We searched four databases: CENTRAL, MEDLINE, PsycINFO, and OpenGrey. Screening of search results, data extraction, and risk of bias assessment were undertaken independently by two reviewers. Results: Eleven studies, reported in 12 papers, involving 2,677 postnatal women were included. All were RCTs, bar one case series. Interventions varied in modality, duration and intensity, and included exposure therapy, trauma-focused cognitive behavioral therapy, eye movement desensitization and reprocessing and other psychological approaches. Participants had experienced uncomplicated births, emergency cesarean sections and/or preterm births. Results suggest that TFPT are effective for reducing PTSD symptoms in the short term (up to 3 months postpartum [4 RCTs, n = 301, SMD = -0.50, 95% CI = -0.73 to -0.27]), and medium term (i.e., 3-6 months postpartum [2 RCTs, n = 174, SMD = -1.87, 95% CI = -2.60 to -1.13]). However, there is no robust evidence to suggest whether TFPT can also improve women's recovery from clinically significant PTSD symptoms. Conclusion: Further larger studies, distinguishing between low and high risk groups, and with adequate follow-up, are needed to establish which TFPT are most effective and acceptable for treating postnatal PTSD.

Changes in birth-related pain perception impact of neurobiological and psycho-social factors

PURPOSE

To analyse post-partum short- and long-term pain sensitivity and the influence of endogenous pain inhibition as well as distinct psycho-social factors on birth-related pain.

METHODS

Pain sensitivity was assessed in 91 primiparous women at three times: 2-6 weeks before, one to 3 days as well as ten to 14 weeks after childbirth. Application of a pressure algometer in combination with a cold pressor test was utilised for measurement of pain sensitivity and assessment of conditioned pain modulation (CPM). Selected psycho-social factors (anxiety, social support, history of abuse, chronic pain and fear of childbirth) were evaluated with standardised questionnaires and their effect on pain processing then analysed.

RESULTS

Pressure pain threshold, cold pain threshold and cold pain tolerance increased significantly directly after birth (all p < 0.001). While cold pain parameters partly recovered on follow-up, pressure pain threshold remained increased above baseline (p < 0.001). These pain-modulating effects were not found for women with history of abuse. While CPM was not affected by birth, its extent correlated significantly (r = 0.367) with the drop in pain sensitivity following birth. Moreover, high trait anxiety predicted an attenuated reduction in pain sensitivity (r = 0.357), while there was no correlation with fear of childbirth, chronic pain and social support.

CONCLUSION

Pain sensitivity showed a decrease when comparing post-partum with prepartum values. The extent and direction of CPM appear to be a trait variable that predicted post-partum hypalgesia without being changed itself. Post-partum hypalgesia was reduced in women with a history of abuse and high trait anxiety, which suggests that individual differences in CPM affect childbirth experience.

Reducing intrusive traumatic memories after emergency caesarean section: A proof-of-principle randomized controlled study

Preventative psychological interventions to aid women after traumatic childbirth are needed. This proof-of-principle randomized controlled study evaluated whether the number of intrusive traumatic memories mothers experience after emergency caesarean section (ECS) could be reduced by a brief cognitive intervention. 56 women after ECS were randomized to one of two parallel groups in a 1:1 ratio: intervention (usual care plus cognitive task procedure) or control (usual care). The intervention group engaged in a visuospatial task (computer-game 'Tetris' via a handheld gaming device) for 15 min within six hours following their ECS. The primary outcome was the number of intrusive traumatic memories related to the ECS recorded in a diary for the week post-ECS. As predicted, compared with controls, the intervention group reported fewer intrusive traumatic memories (M = 4.77, SD = 10.71 vs. M = 9.22, SD = 10.69, d = 0.647 [95% CI: 0.106, 1.182]) over 1 week (intention-to-treat analyses, primary outcome). There was a trend towards reduced acute stress re-experiencing symptoms (d = 0.503 [95% CI: -0.032, 1.033]) after 1 week (intention-to-treat analyses). Times series analysis on daily intrusions data confirmed the predicted difference between groups. 72% of women rated the intervention "rather" to "extremely" acceptable. This represents a first step in the development of an early (and potentially universal) intervention to prevent postnatal posttraumatic stress symptoms that may benefit both mother and child.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT02502513.

Commentary on a Cochrane Review of Debriefing Interventions for the Prevention of Psychological Trauma in Women After Childbirth

Childbirth can be a traumatic event for some women, with psychological effects that can be significant and long-lasting. Authors of a Cochrane Review of seven randomized controlled trials concluded that debriefing interventions for women after childbirth are not well-defined in the literature and that not enough evidence exists to conclude that there is a positive or adverse effect from using these interventions.

Women's descriptions of childbirth trauma relating to care provider actions and interactions

Background

Many women experience psychological trauma during birth. A traumatic birth can impact on postnatal mental health and family relationships. It is important to understand how interpersonal factors influence women’s experience of trauma in order to inform the development of care that promotes optimal psychosocial outcomes.

Methods

As part of a large mixed methods study, 748 women completed an online survey and answered the question ‘describe the birth trauma experience, and what you found traumatising’. Data relating to care provider actions and interactions were analysed using a six-phase inductive thematic analysis process.

Results

Four themes were identified in the data: ‘prioritising the care provider’s agenda’; ‘disregarding embodied knowledge’; ‘lies and threats’; and ‘violation’. Women felt that care providers prioritised their own agendas over the needs of the woman. This could result in unnecessary intervention as care providers attempted to alter the birth process to meet their own preferences. In some cases, women became learning resources for hospital staff to observe or practice on. Women’s own embodied knowledge about labour progress and fetal wellbeing was disregarded in favour of care provider’s clinical assessments. Care providers used lies and threats to coerce women into complying with procedures. In particular, these lies and threats related to the wellbeing of the baby. Women also described actions that were abusive and violent. For some women these actions triggered memories of sexual assault.

Conclusion

Care provider actions and interactions can influence women’s experience of trauma during birth. It is necessary to address interpersonal birth trauma on both a macro and micro level. Maternity service development and provision needs to be underpinned by a paradigm and framework that prioritises both the physical and emotional needs of women. Care providers require training and support to minimise interpersonal birth trauma.