Evaluation of expressive writing for postpartum health: a randomised controlled trial

Writing to Keep on Living: A Systematic Review and Meta-Analysis on Creative Writing Therapy for the Management of Depression and Suicidal Ideation

PURPOSE OF REVIEW

The purpose of this review and meta-analysis was to explore the effectiveness of creative writing therapies for the management of depression and suicidal ideation.

RECENT FINDINGS

Twenty one of the 31 reviewed studies showed that creative writing significantly improved depressive symptoms, while five studies suggested improvement in other symptoms. The results of meta-analyses showed that narrative writing significantly reduced depression compared to those in neutral writing or treatment as usual condition in both post intervention and follow-up. However, the number of studies exploring the effects of creative writing in suicidal ideation was too low to perform a meta-analysis. A structured and well-targeted intervention using creative writing could have beneficial results for the management of depressive symptoms. More studies are needed to explore the potential benefits of creative writing for reducing suicidal ideation.

The effect of an attachment-based intervention program on attachment, expectation, and stress in pregnant women: A randomized controlled study

AIM

This study aimed to determine the effect of an attachment-based intervention program (ABIP) on attachment, prenatal expectation and stress levels in pregnant women.

METHODS

This randomized controlled study was conducted in the pregnant outpatient clinics of a public hospital in Turkey. The study sample consisted of a total of 154 pregnant women (77 experimental, 77 control) at 28-38 weeks of gestation. The ABIP was applied to the pregnant women in the experimental group for 5-7 days. The ABIP included five interventions: (1) perceiving/counting fetal movements; (2) music therapy; (3) preparation for the baby; (4) writing notes/letters to the baby; and (5) watching images of the fetus/pregnancy.

RESULTS

After the ABIP, pregnant women in the experimental group had higher prenatal maternal attachment and prenatal positive expectation mean scores than those in the control group, and the difference between them was statistically significant in favor of those in the experimental group (P < .001). In addition, pregnant women in the experimental group had lower prenatal negative expectation and prenatal distress mean scores than those in the control group, and the difference between them was statistically significant in favor of those in the experimental group (P < .001).

CONCLUSIONS

The results of this study suggest that ABIP is a unique and pioneering program to increase maternal-antenatal attachment and prenatal positive expectations and reducing prenatal negative expectations and distress through diverse interventions. However, further research is required to assess the effectiveness of ABIP on maternal-fetal attachment, prenatal maternal expectations, and prenatal distress.

Interventions from pregnancy to two years after birth for parents experiencing complex post-traumatic stress disorder and/or with childhood experience of maltreatment

BACKGROUND

Acceptable, effective and feasible support strategies (interventions) for parents experiencing complex post-traumatic stress disorder (CPTSD) symptoms or with a history of childhood maltreatment may offer an opportunity to support parental recovery, reduce the risk of intergenerational transmission of trauma and improve life-course trajectories for children and future generations. However, evidence relating to the effect of interventions has not been synthesised to provide a comprehensive review of available support strategies. This evidence synthesis is critical to inform further research, practice and policy approaches in this emerging area.

OBJECTIVES

To assess the effects of interventions provided to support parents who were experiencing CPTSD symptoms or who had experienced childhood maltreatment (or both), on parenting capacity and parental psychological or socio-emotional wellbeing.

SEARCH METHODS

In October 2021 we searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers, together with checking references and contacting experts to identify additional studies.

SELECTION CRITERIA

All variants of randomised controlled trials (RCTs) comparing any intervention delivered in the perinatal period designed to support parents experiencing CPTSD symptoms or with a history of childhood maltreatment (or both), to any active or inactive control. Primary outcomes were parental psychological or socio-emotional wellbeing and parenting capacity between pregnancy and up to two years postpartum.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of trials for inclusion, extracted data using a pre-designed data extraction form, and assessed risk of bias and certainty of evidence. We contacted study authors for additional information as required. We analysed continuous data using mean difference (MD) for outcomes using a single measure, and standardised mean difference (SMD) for outcomes using multiple measures, and risk ratios (RR) for dichotomous data. All data are presented with 95% confidence intervals (CIs). We undertook meta-analyses using random-effects models.

MAIN RESULTS

We included evidence from 1925 participants in 15 RCTs that investigated the effect of 17 interventions. All included studies were published after 2005. Interventions included seven parenting interventions, eight psychological interventions and two service system approaches. The studies were funded by major research councils, government departments and philanthropic/charitable organisations. All evidence was of low or very low certainty. Parenting interventions Evidence was very uncertain from a study (33 participants) assessing the effects of a parenting intervention compared to attention control on trauma-related symptoms, and psychological wellbeing symptoms (postpartum depression), in mothers who had experienced childhood maltreatment and were experiencing current parenting risk factors. Evidence suggested that parenting interventions may improve parent-child relationships slightly compared to usual service provision (SMD 0.45, 95% CI -0.06 to 0.96; I2 = 60%; 2 studies, 153 participants; low-certainty evidence). There may be little or no difference between parenting interventions and usual perinatal service in parenting skills including nurturance, supportive presence and reciprocity (SMD 0.25, 95% CI -0.07 to 0.58; I2 = 0%; 4 studies, 149 participants; low-certainty evidence). No studies assessed the effects of parenting interventions on parents' substance use, relationship quality or self-harm. Psychological interventions Psychological interventions may result in little or no difference in trauma-related symptoms compared to usual care (SMD -0.05, 95% CI -0.40 to 0.31; I2 = 39%; 4 studies, 247 participants; low-certainty evidence). Psychological interventions may make little or no difference compared to usual care to depression symptom severity (8 studies, 507 participants, low-certainty evidence, SMD -0.34, 95% CI -0.66 to -0.03; I2 = 63%). An interpersonally focused cognitive behavioural analysis system of psychotherapy may slightly increase the number of pregnant women who quit smoking compared to usual smoking cessation therapy and prenatal care (189 participants, low-certainty evidence). A psychological intervention may slightly improve parents' relationship quality compared to usual care (1 study, 67 participants, low-certainty evidence). Benefits for parent-child relationships were very uncertain (26 participants, very low-certainty evidence), while there may be a slight improvement in parenting skills compared to usual care (66 participants, low-certainty evidence). No studies assessed the effects of psychological interventions on parents' self-harm. Service system approaches One service system approach assessed the effect of a financial empowerment education programme, with and without trauma-informed peer support, compared to usual care for parents with low incomes. The interventions increased depression slightly (52 participants, low-certainty evidence). No studies assessed the effects of service system interventions on parents' trauma-related symptoms, substance use, relationship quality, self-harm, parent-child relationships or parenting skills.

AUTHORS' CONCLUSIONS

There is currently a lack of high-quality evidence regarding the effectiveness of interventions to improve parenting capacity or parental psychological or socio-emotional wellbeing in parents experiencing CPTSD symptoms or who have experienced childhood maltreatment (or both). This lack of methodological rigour and high risk of bias made it difficult to interpret the findings of this review. Overall, results suggest that parenting interventions may slightly improve parent-child relationships but have a small, unimportant effect on parenting skills. Psychological interventions may help some women stop smoking in pregnancy, and may have small benefits on parents' relationships and parenting skills. A financial empowerment programme may slightly worsen depression symptoms. While potential beneficial effects were small, the importance of a positive effect in a small number of parents must be considered when making treatment and care decisions. There is a need for further high-quality research into effective strategies for this population.

Creative arts intervention in support of women experiencing a high-risk pregnancy: A qualitative descriptive thematic analysis

BACKGROUND

Mental illness can have negative effects on both the pregnant woman and her unborn child. Studies that use the creative arts as interventions have proven to be beneficial to women's antenatal mental health and wellbeing, however, these studies are limited and emergent. Music, drawing and narrative (MDN) is an established music therapy intervention, stemming from guided imagery and music (GIM), that has the potential to support positive mental health and wellbeing. Yet, to date, there have been limited studies on the use of this form of therapy with inpatient antenatal women.

AIM

To describe antenatal inpatient women's experiences of participating in a MDN session.

METHODS

Qualitative data were collected from a sample of 12 inpatient pregnant women who participated in MDN group sessions of drawing to music. Post intervention interviews explored the mental and emotional health of participants. A thematic analysis of the transcribed interview data was performed.

FINDINGS

Through reflection women were supported to acknowledge both the positives and difficulties of pregnancy as well as establish meaningful connections through shared experience. These thematic findings highlighted that MDN enabled this group of pregnant women to better communicate their feelings, validate emotions, engage in positive distractions, develop greater connections, improve optimism, experience calmness, and learn from others.

CONCLUSION

This project demonstrates that MDN may offer a viable method for supporting women experiencing high risk pregnancies.

Quality of Life instruments and their psychometric properties for use in parents during pregnancy and the postpartum period: a systematic scoping review

Purpose

To identify instruments used to measure parents’ Quality of Life (QoL) during pregnancy and the postpartum period, and to describe their characteristics and psychometric properties.

Methods

For this scoping review we conducted systematic literature searches in MEDLINE, EMBASE, PsychINFO, CINAHL and HaPI in mid-December 2020, to identify studies evaluating psychometric properties. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) were used to define and categorize psychometric properties. Two reviewers screened the studies independently, and customized screening questions were used to assess eligibility against inclusion criteria. Data were systematically extracted into a predesigned data charting matrix, and descriptively analyzed.

Results

The searches identified 5671 studies, of which 53 studies met the inclusion criteria. In total, there were 19 QoL instruments: 12 generic and seven period specific. The most reported instruments were SF-36, SF-12 and WHOQOL-BREF, and the most evaluated instruments were SF-12, WHOQOL-BREF, QOL-GRAV, and PQOL. We found that none of the identified instruments had been evaluated for all nine psychometric properties recommended by the COSMIN. The most reported psychometric properties were internal consistency and structural validity. The instruments were primarily assessed in parents residing in Asia (50%), and 83% of the studies were conducted from 2010 to 2020. Only three studies included psychometric measures assessed on fathers.

Conclusion

Our review shows there is extensive evidence on the internal consistency and structural validity of QoL instruments used on parents during pregnancy and the postpartum period, but that the evidence on other psychometric properties is sparse. Validation studies and primary studies are needed to provide evidence on the reliability, validity, responsiveness, and interpretability of QoL instruments for this target group, in particular for fathers and partners.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-02011-y.

Bactericidal Properties of Low-Density Polyethylene (LDPE) Modified with Commercial Additives Used for Food Protection in the Food Industry

This study investigated the influence of commercially available food preservatives: Natamax® (containing natamycin) and Nisaplin® (containing nisin) on the antimicrobial properties of LDPE film, commonly used for food packaging. Studies have shown that the addition of 3% Natamax® or, alternatively, the addition of 5% Nisaplin® provides an LDPE film with effective antimicrobial protection. The applied biocides did not significantly affect the strength and rheological properties of LDPE. However, differences in optical properties were observed. The transparency of the samples decreased slightly with the addition of 3% or 5% Natamax® (by approx. 1% and 3%, respectively). A significant change was observed in the film haze, the addition of 5% Natamax® increased this parameter by approx. 80%, while 5% Nisaplin® increased it by approx. 19%. Both Natamax® and Nisaplin® agents can be successfully used to manufacture food packaging materials with antimicrobial protection. Natamax® showed a stronger bactericidal effect, while Nisaplin® changed other properties less significantly.

Holistic Psychosocial Approaches in the Care of Hispanic Victims of Trauma: An Overview

The collapse of the Champlain Towers South (CTS), a condominium in Miami, Florida, left a diverse group of survivors and healthcare clinicians tasked with finding ways of coping with the disaster. Within seconds, the CTS collapse became a global tragedy due to the coastal neighborhood's rich international mix of residents. Although this tragedy impacted communities across globe, a large population of Hispanic victims lived in CTS that were deeply affected. Culturally adaptive interventions and holistic healthcare for Hispanic individuals are highly relevant because Hispanic Americans represent one of the fastest growing demographic groups in the United States. To reach, engage, and address the needs of Hispanic victims, this article provides an overview of psychosocial factors that influence Hispanic victims with trauma and discusses holistic psychotherapeutic approaches in nursing care that can be applied to improve victims' well-being. Culture is an important consideration in health; therefore, this article highlights and operationalizes culturally tailored holistic nursing care that draws from the physical, mental, emotional, and spiritual dimensions of health and well-being that can be used in clinical settings with Hispanic clients who have experienced trauma.

Effects of an expressive writing intervention in Chinese women undergoing pregnancy termination for fetal abnormality: A randomized controlled trial

OBJECTIVE

To explore the efficacy of an expressive writing intervention on promoting psychological well-being of women who have had a diagnosis of fetal abnormality.

DESIGN AND SETTING

An open, randomized controlled trial with parallel group design was conducted at a tertiary hospital in China. 100 women were randomly assigned into either the expressive writing (EW) intervention group or the control group, and 80 women eventually took part in all the phases of the study. Psychological variables including post-traumatic growth (PTG), post-traumatic stress disorder (PTSD) and resilience were assessed at baseline, immediately after the intervention and 1-month follow-up.

PARTICIPANTS

Women who have had a diagnosis of fetal abnormalities and decided to terminate pregnancies.

INTERVENTION

Women in the intervention group were asked to write three 15 min essays in regard to their experiences with the fetal abnormalities.

FINDINGS

The intervention group had significantly higher level of PTG (p = 0.003) and lower level of PTSD symptoms (p = 0.023) immediately after the intervention, as compared with the control group. In 1-month follow-up, intervention participants demonstrated significant improvement in PTG (p = 0.014) but insignificant reduction for PTSD symptoms. No significant effects were observed in both groups in terms of changes over time in resilience.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

EW is efficacious for improving women's PTG and easing their symptoms of PTSD to some extent. Medical staff should pay more attention to this population's psychological status. In the future, EW interventions need to be conducted in larger samples with more severe symptoms of PTSD to validate its effectiveness. The efficacy of longer and more frequent writing interventions should also be investigated.

Unexpected effects of expressive writing on post-disaster distress in the Hurricane Harvey Study: a randomized controlled trial in perinatal women

BACKGROUND

Expressive writing requires journaling stressor-related thoughts and feelings over four daily sessions of 15 min. Thirty years of research have popularized expressive writing as a brief intervention for fostering trauma-related resilience; however, its ability to surpass placebo remains unclear. This study aimed to determine the efficacy of expressive writing for improving post-traumatic stress symptoms in perinatal women who were living in the Houston area during major flooding caused by Hurricane Harvey.

METHODS

A total of 1090 women were randomly allocated (1:1:1) to expressive writing, neutral writing or no writing. Interventions were internet-based. Online questionnaires were completed before randomization and at 2 months post-intervention. The primary outcome was post-traumatic stress symptoms, measured with the Impact of Event Scale-Revised; secondary outcomes were affective symptoms, measured with the 40-item Inventory of Depression and Anxiety Scales. Feelings throughout the intervention were reported daily using tailored questionnaires.

RESULTS

In intention-to-treat analyses, no post-treatment between-group differences were found on the primary and secondary outcomes. Per-protocol analyses yielded similar results. A number of putative moderators were tested, but none interacted with expressive writing. Expressive writing produced greater feelings of anxiety and sadness during the intervention compared to neutral writing; further, overall experiences from the intervention mediated associations between expressive writing and greater post-traumatic stress at 2 months post-intervention.

CONCLUSIONS

Among disaster-stricken perinatal women, expressive writing was ineffective in reducing levels of post-traumatic stress, and may have exacerbated these symptoms in some.

Effects of psychological stress on adverse pregnancy outcomes and nonpharmacologic approaches for reduction: an expert review

Both acute and chronic stress can cause allostatic overload, or long-term imbalance in mediators of homeostasis, that results in disruptions in the maternal-placental-fetal endocrine and immune system responses. During pregnancy, disruptions in homeostasis may increase the likelihood of preterm birth and preeclampsia. Expectant mothers traditionally have high rates of anxiety and depressive disorders, and many are susceptible to a variety of stressors during pregnancy. These common life stressors include financial concerns and relationship challenges and may be exacerbated by the biological, social, and psychological changes occurring during pregnancy. In addition, external stressors such as major weather events (eg, hurricanes, tornados, floods) and other global phenomena (eg, the coronavirus disease 2019 pandemic) may contribute to stress during pregnancy. This review investigates recent literature published about the use of nonpharmacologic modalities for stress relief in pregnancy and examines the interplay between psychiatric diagnoses and stressors, with the purpose of evaluating the feasibility of implementing nonpharmacologic interventions as sole therapies or in conjunction with psychotherapy or psychiatric medication therapy. Further, the effectiveness of each nonpharmacologic therapy in reducing symptoms of maternal stress is reviewed. Mindfulness meditation and biofeedback have shown effectiveness in improving one's mental health, such as depressive symptoms and anxiety. Exercise, including yoga, may improve both depressive symptoms and birth outcomes. Expressive writing has successfully been applied postpartum and in response to pregnancy challenges. Although some of these nonpharmacologic interventions can be convenient and low cost, there is a trend toward inconsistent implementation of these modalities. Future investigations should focus on methods to increase ease of uptake, ensure each option is available at home, and provide a standardized way to evaluate whether combinations of different interventions may provide added benefit.

[Postpartum care for women in primary care: building an assessment model]

Postpartum care for women in primary healthcare (PHC) is important for reducing their morbimortality, but there is no clearly described theory on such care, and the assessment studies are rare. This study aimed to develop and systematize an assessment model for women's postpartum care in PHC, verifying it evaluability. An evaluability study was performed using a Brazilian and international literature review, review of national documents, and interviews with stakeholders. Such evidence backed the elaboration of an assessment model that was validated in a consensus workshop. The data were analyzed with thematic analysis. The study elaborated the program's theory, in which postpartum care in PHC ideally takes place with a comprehensive approach to the woman's physical, psychological, emotional, and social needs, considering the individuality of women with liveborn children or in situations of fetal/neonatal death, initiating prenatal care and continuity in the postpartum period, and with the involvement of spouses and other family members. The program's theory established the program's contextualization and logical design, with objectives, targets, activities, outputs, results, and impact, previously not explained systematically in the literature and documents. Postpartum care was found to be evaluable through an implementation analysis, and the program's theory was defined, with the potential for use by various stakeholders at both the national and international levels to implement and/or improve comprehensive postpartum care for women.

Effects of expressive writing intervention for women's PTSD, depression, anxiety and stress related to pregnancy: A meta-analysis of randomized controlled trials

Expressive writing (EW) is a common psychological intervention that aims to improve the mental health of traumatized individuals. Pregnancy is considered an anxious or traumatic experience for some women, and any crisis in relation to pregnancy is closely associated with their psychological well-being. Post-traumatic stress disorder (PTSD), depression, anxiety and stress are the most prominent emotional and psychological responses that may occur during the process. However, the effects of EW in mediating women's PTSD, depression, anxiety and stress related to pregnancy remain uncertain, and no qualified meta-analysis has assessed such effects. The aim of this study was to assess the effectiveness of EW as a psychological intervention for women. Five databases, including PubMed, EMBASE, Cochrane, Web of Science and PsycINFO, were searched from inception to September 2019 for eligible studies. Finally, a total of 929 participants from 8 randomized controlled trial (RCT) studies were included. A pooled analysis demonstrated that EW was an efficient therapy for decreasing PTSD. However, the results showed that the EW intervention was not associated with the expected effects on anxiety and stress symptoms. The efficacy of EW for depression was inconclusive. More RCTs are necessary to verify the effectiveness of EW for depression. Studies concentrating on EW's effects on physical symptoms are necessary, and researchers should create an EW intervention group, neutral writing group and no writing group to examine the true effects of EW. Future research should examine whether longer, more frequent, and more targeted writing interventions would result in different conclusions.

What are women stressed about after birth?

BACKGROUND

Having a baby is associated with a variety of stressors, change, and adjustment. This study aimed to identify what women find stressful during the early postpartum period in contemporary Western society.

METHODS

Women (n = 148) 6-12 weeks postpartum wrote anonymously about a situation they found stressful as part of the Health after Birth Trial (HABiT) of expressive writing. Transcripts were analyzed for categories of stressors and cross-cutting themes.

RESULTS

Five categories of stressors were identified. Stressors in pregnancy, labor, and the early postpartum period (49.3%) included physical and emotional difficulties, and insensitive treatment by health professionals. Stressors related to adjusting to life with a baby (35.8%) included difficulties coping with a new baby, parenting, juggling responsibilities, changes to physical health, and loneliness. Stressors related to the baby's health (32.4%) included infant digestive problems, acute health problems, long-term impact, and neonatal intensive care unit experiences. Stressors related to breastfeeding (23.7%) included pressure to breastfeed, feeling like a 'bad mum' for not breastfeeding, or wanting to breastfeed and not being able to. Other stressors related to changing relationships (18.2%): with their partner, children, and other family members. Cross-cutting themes that emerged in different stressor categories were women making negative self-appraisals (eg, a bad mum, failure), feeling guilty, and lack of support from others.

DISCUSSION

Our findings emphasize the importance of exploring stressors and psychological well-being with women to provide support, help women's adjustment postpartum, and ensure interventions are offered when appropriate.

Feasibility and acceptability of expressive writing with postpartum women: a randomised controlled trial

Background

Pregnancy, birth and adjusting to a new baby is a potentially stressful time that can negatively affect women’s mental and physical health. Expressive writing, where people write about a stressful event for at least 15 min on three consecutive days, has been associated with improved health in some groups but it is not clear whether it is feasible and acceptable for use with postpartum women. This study therefore examined the feasibility and acceptability of expressive writing for postpartum women as part of a randomised controlled trial (RCT).

Methods

The Health After Birth Trial (HABiT) was an RCT evaluating expressive writing for postpartum women which included measures of feasibility and acceptability. At 6 to 12 weeks after birth 854 women were randomised to expressive writing, a control writing task or normal care, and outcome measures of health were measured at baseline, one month later and six months later. Feasibility was measured by recruitment, attrition, and adherence to the intervention. Quantitative and qualitative measures of acceptability of the materials and the task were completed six months after the intervention.

Results

Recruitment was low (10.7% of those invited to participate) and the recruited sample was from a restricted sociodemographic range. Attrition was high, increased as the study progressed (35.8% at baseline, 57.5% at one month, and 68.1% at six months) and was higher in the writing groups than in the normal care group. Women complied with instructions to write expressively or not, but adherence to the instruction to write for 15 min per day for three days was low (Expressive writing: 29.3%; Control writing: 23.5%). Acceptability measures showed that women who wrote expressively rated the materials/task both more positively and more negatively than those in the control writing group, and qualitative comments revealed that women enjoyed the writing and/or found it helpful even when it was upsetting.

Conclusions

The feasibility of offering expressive writing as a universal self-help intervention to all postpartum women 6 to 12 weeks after birth in the HABiT trial was low, but the expressive writing intervention was acceptable to the majority of women who completed it.

Trial registration

ISRCTN58399513, 10/09/2013.