A review of the literature on debriefing or non-directive counselling to prevent postpartum emotional distress

Effect of psychological interventions on mental health, personal relationships and quality of life of women who have subjectively experienced traumatic childbirth

BACKGROUND

No targeted review has assessed the effect of psychological interventions on the mental health, personal relationships, and the quality of life of women who have subjectively experienced traumatic childbirth.

METHODS

Eight databases were searched from inception to January 2023. Study selection, data extraction, quality appraisal, and data analysis were conducted by two researchers independently.

RESULTS

In total, eight studies were included. The results indicated that psychological interventions could effectively alleviate post-traumatic stress disorder (PTSD) symptoms, depression, and anxiety in women who have subjectively experienced traumatic childbirth. The interventions were more effective in alleviating PTSD symptoms than depression or anxiety. The subgroup analysis results showed that the effect of multiple sessions might be better than that of a single session. There was insufficient evidence supporting the effect of psychological interventions to improve personal relationships and the quality of life.

LIMITATIONS

Study limitations included the small number of studies included for meta-analysis, substantial heterogeneity, and the retrieval of only studies written in English or Chinese.

CONCLUSIONS

Psychological intervention is a promising method for the mental health of women who have subjectively experienced traumatic childbirth, but more studies are needed to confirm the effects. More studies are also required to explore the impact of psychological interventions on personal relationships and the quality of life. Future studies should focus on comparing which specific type of psychological intervention is most effective. Additional investigations should include the potential adverse effects and long-term effects of psychological interventions and details, such as content, process, and timing.

Effectiveness of Psychological Interventions to Improve the Mental Well-Being of Parents Who Have Experienced Traumatic Childbirth: A Systematic Review and Meta-Analysis

Considering the adverse impact that traumatic childbirth experiences can have on parental mental well-being, studies that have investigated the potential of providing postnatal psychological support for this group of parents require evaluation. This systematic review aimed to examine the effectiveness of psychological interventions at improving the mental well-being of parents who have experienced traumatic childbirth in terms of anxiety, depression, fear of childbirth, and post-traumatic stress disorder (PTSD) symptoms. Seven electronic databases were searched from their respective inception dates up to January 2021. Only quantitative studies that reported the effects of psychological interventions on anxiety, depression, fear of childbirth, and/or PTSD symptoms in selective (at risk of traumatic childbirth experience) or indicated (self-defined childbirth experience as traumatic for any reason) populations of parents (mothers and/or fathers) were included. Eight studies were included and meta-analyses were conducted using a random-effect model. All studies were conducted on mothers only, and one study had minimal father involvement. Results showed that psychological interventions were more effective in reducing fear of childbirth and improving PTSD symptoms compared to anxiety and depression. Greater improvement in depression was reported at 3-8 weeks' follow-up than at immediate post-intervention. Subgroup analyses showed that technology-based interventions were feasible, and indicated interventions were more effective than selective interventions. Conducting future interventions in more geographical regions, engaging and including fathers more actively, incorporating both personalized professional therapy and informal peer support, striving for flexibility and convenience, as well as addressing topics on self-doubt and coping skills can improve current interventions.

Women report better experiences from maternity care after postnatal consultations: A cross sectional study

OBJECTIVE

To determine if the patient reported experiences (PREMs) of women in maternity care differ by whether or not they had a postnatal consultation before leaving the birth institution.

METHODS

Secondary analysis of cross-sectional data to compare PREMs of women who had received an individual consultation (86 %), a group consultation (3 %), and women who had received no consultation (11 %). PREMs were collected using a self-administered questionnaire. Eight summated scales were constructed from 29 single items, pertaining to different parts of the received care. Scores ranged between 0 and 100, with high scores representing positive experiences.

RESULTS

Among the 8156 sampled women, 3387 (42 %) responded. There were statistically significant (p ≤ 0.002) differences (from 3.7 to 16.3 points) on all eight scales. The scores from women who had an individual postnatal consultation were consistently higher than the scores from the other groups. The largest difference was in the scale with the worst score: information about women's health during the postnatal stay.

CONCLUSION

Women who participated in individual postnatal consultations reported more positive experiences compared to those who did not.

PRACTICE IMPLICATION

The consistent differences found in this study provide support for administering individual postnatal consultations.

A randomized controlled clinical trial of the effect of supportive counseling on mental health in Iranian mothers of premature infants

Background

Premature birth can affect maternal mental health. Considering that the mental health disorder in mothers may play a vital role in the growth and development of their children, therefore, this study was conducted to determine the effect of supportive counseling on mental health (primary outcome), mother-child bonding and infant anthropometric indices (secondary outcomes) in mothers of premature infants.

Methods

This randomized controlled clinical trial was carried out on 66 mothers with hospitalized neonates in the NICU of Alzahra hospital in Tabriz- Iran. Participants were randomly allocated into two groups of intervention (n = 34) and control (n = 32) through a block randomization method. The intervention group received 6 sessions of supportive counseling (45–60 minutes each session) by the researcher, and the control group received routine care. Questionnaires of Goldberg General Health and the postpartum bonding were completed before the intervention (first 72 hours postpartum) and 8 weeks postpartum. Also, the anthropometric index of newborns were measured at the same time.

Results

There was no statistically significant difference between the two groups in terms of socio-demographic characteristics. After the intervention, based on ANCOVA with adjusting the baseline score, mean score of mental health (AMD: -9.8; 95% Confident Interval (95% CI): -12.5 to -7.1; P < 0.001) and postpartum bonding (AMD: -10.0; 95% CI: -0.6 to 13.9; P < 0.001) in the counseling group was significantly lower than those of the control group; however, in terms of weight (P = 0.536), height (P = 0.429) and head circumference (P = 0.129), there was no significant difference between the two groups.

Conclusions

Supportive counseling may improve mental health and postpartum bonding in mothers of premature infants. Thus, it may be recommendable for health care providers to offer it to mothers.

Trial registration

Iranian Registry of Clinical Trials (IRCT): IRCT20120718010324N45. Date of registration: October 29, 2018.

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.

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.

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

BACKGROUND

Childbirth is a complex life event that can be associated with both positive and negative psychological responses. When giving birth is experienced as particularly traumatic this can have a negative impact on a woman's postnatal emotional well-being. There has been an increasing focus on women's psychological trauma symptoms following childbirth, including the relatively rare phenomenon of post-traumatic stress disorder (PTSD), and the benefit of debriefing interventions to prevent this. In this review we examined the evidence for debriefing as a preventative intervention for psychological trauma following childbirth.

OBJECTIVES

To assess the effects of debriefing interventions compared with standard postnatal care for the prevention of psychological trauma in women following childbirth.

SEARCH METHODS

The trials registers of the Cochrane Depression, Anxiety and Neurosis Group (CCDANCTR-References and CCDANCTR-Studies) and the Cochrane Pregnancy and Childbirth Group were searched up to 4 March 2015. These registers include relevant randomised controlled trials from the following bibliographic databases: the Cochrane Library (all years to date), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). Additional searches were conducted in CENTRAL, MEDLINE, EMBASE, PsycINFO, and Maternity and Infant Care. The reference lists of all included studies were checked for additional published reports and citations of unpublished research. Experts in the field were contacted.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised trials comparing postnatal debriefing interventions with standard postnatal care for the prevention of psychological trauma of women following childbirth. The intervention consisted of at least one debriefing intervention session, which had the purpose of allowing women to describe their experience and to normalise their emotional reaction to that experience.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality and extracted data. Meta-analysis was conducted where there were more than two trials examining the same outcomes.

MAIN RESULTS

We included seven trials (eight articles) from three countries (UK, Australia and Sweden) that fulfilled the inclusion criteria. The number of women contributing data to each outcome varied from 102 to 1745. Methodological quality was variable and most of the studies were of low quality. The quality of evidence for the prevalence of psychological trauma (primary outcome) and the prevalence of depression symptoms was rated low or very low, based on few studies (ranging from a single study to three studies) with high risk of bias in main domains such as performance bias, random sequence generation, allocation concealment and incomplete outcome data. The quality of evidence for the remaining outcomes (that is prevalence of anxiety, prevalence of fear of childbirth, prevalence of general psychological morbidity, health service utilization and attrition from treatment) was not assessed as data were not available.Among women who had a high level of obstetric intervention during labour and birth, we found no difference between standard postnatal care with debriefing and standard postnatal care without debriefing on psychological trauma symptoms within three months postpartum (RR 0.61; 95% CI 0.28 to 1.31; n = 425) or at three to six months postpartum (RR 0.62; 95% CI 0.27 to 1.42; n = 246). The results were based on two trials, respectively. Among women who experienced a distressing or traumatic birth, there was no evidence of an effect of psychological debriefing on the prevention of PTSD (measured by the MINI-PTSD) at four to six weeks postpartum (RR 1.15; 95% CI 0.66 to 2.01; n = 102) or at six months (RR 0.35; 95% CI 0.10 to 1.23; n = 103). The results were based on one small trial. One trial involving low-risk women who delivered healthy infants at or near term reported no significant difference between the intervention group and the control group in the proportion of women who met the diagnostic criteria for psychological trauma during the year following childbirth (RR 1.06; 95% CI 0.88 to 1.28; n = 1745). We did not find any information about attrition rates.

AUTHORS' CONCLUSIONS

We did not find any high quality evidence to inform practice, with substantial heterogeneity being found between the studies conducted to date. There is little or no evidence to support either a positive or adverse effect of psychological debriefing for the prevention of psychological trauma in women following childbirth. There is no evidence to support routine debriefing for women who perceive giving birth as psychologically traumatic.Future research should provide greater detail of the outcome measures used, and with scales for measuring psychological trauma validated against clinical diagnostic interviews. High rates of obstetric intervention in some birth settings may mean that women require improved emotional care from health professionals to reduce the risk of childbirth being experienced as traumatic. As all included trials excluded women unable to communicate in the native language of the study setting, there is no information on the response of these women to psychological debriefing. No included studies were conducted in low or middle-income countries.

Childbirth-related post-traumatic stress disorder and its treatment

The phenomenon of childbirth-related post-traumatic stress disorder (PTSD) has become more widely recognised in recent years following changes in 1994 to the DSM criteria regarding how a traumatic event was defined. Emerging literature has predominately focused on prevalence rates and risk factors associated with this condition and on the use of debriefing techniques as an attempt to reduce or prevent the development of postnatal PTSD. However, little is known about the efficacy of psychological interventions that have been used to treat PTSD among postnatal women. This review summarises the limited evidence supporting the use of such treatments and discusses the significant challenges in developing and implementing psychological interventions for childbirth-related PTSD.

Mothers' response to psychological birth trauma: a qualitative study

BACKGROUND

Psychologically traumatic events can affect anybody, but consequences of psychological birth trauma for the mother are very profound, extensive and unforgettable. Furthermore, the mother's response not only touches the mother, but also affects the child, the father and the society. The objective of this study was to explore the mothers' response to psychological birth trauma.

OBJECTIVES

Psychological birth trauma is a complex matter as the length of a women`s life and mother`s responds can be present through different psychological and physical ways. In this regard, the mothers suffer from its consequences, but they do not know what is going on? Mothers are getting worse every day by "the silent effects of the psychological phenomena".

MATERIALS & METHODS

This qualitative study was conducted on 23 mothers with psychological birth trauma experience, who were recruited from health centers of the capital and one of the metropolises of Iran. Their interviews were transcribed verbatim and analyzed by the content analysis method.

RESULTS

THREE THEMES WERE EXTRACTED FROM THE DATA: impact on health, changes in mother`s roles, and changes decision making ability. Several categories and sub-categories also emerged from the data (physical and psychological problems, bonding with the child, relationship with husband, social role, cesarean request and psychological inability to have another child).

CONCLUSIONS

By considering the mothers` responses to traumatic labor, which endangers the health of the child as well as that of the mother and impairs their familial and social relationships, midwives should notice the consequences of psychological birth trauma in order to plan supportive and timely interventions.

The decision-making process of young adult women with cancer who considered fertility cryopreservation

OBJECTIVE

To provide an in-depth description of the decision-making process that women who are diagnosed with cancer undergo as they decide whether to accept or decline fertility cryopreservation.

DESIGN

A qualitative, grounded theory approach.

SETTING AND PARTICIPANTS

Twenty-seven women (mean age = 29 years) who were diagnosed with cancer and were eligible for egg, embryo, or ovarian tissue cryopreservation were recruited from the Internet and two university centers.

METHODS

Each woman participated in a semistructured interview by phone (n = 21) or e-mail (n = 6). Data were analyzed using the constant-comparative method to inductively ascertain the women's decision-making process. NVivo 8 software was used to assist with data retrieval and analysis.

RESULTS

The decision-making process consists of four major phases that women experience to actively formulate a decision: identify, contemplate, resolve, and engage. In the identify phase, women acquire knowledge and experience a "double hit" scenario that is often devastating. Within the contemplate phase, five interrelated dimensions emerged including constructing and/or endorsing preferences and values and undergoing decisional debriefing sessions. A decision is reached in the resolve phase and carried out in the engage phase. Among the participants, 14 declined fertility cryopreservation and 13 accepted egg and/or embryo cryopreservation.

CONCLUSION

The descriptive theoretical framework clarifies the underlying processes that women with cancer undergo to decide about fertility cryopreservation. Quality of care for women with cancer can be improved by implementing appropriately timed information and tailored developmental and contextual counseling to support decision making.

Antenatal diagnosis of congenital anomaly: a really traumatic experience?

OBJECTIVE

With increasing use of routine prenatal ultrasound, prenatal counseling after diagnosis of congenital malformations is frequently offered to prospective parents. We aimed to assess if the communication of diagnosis of a congenital anomaly in the fetus meets American Psychiatric Association (APA) criteria for trauma in parents.

STUDY DESIGN

In the period ranging from 2003 to 2009 a preliminary investigation was conducted with 165 prospective mothers and 91 prospective fathers being interviewed after communication of diagnosis. Analysis of statements was made independently by two psychologists considering the APA definition of trauma.

RESULT

A total of 145 mothers and 76 fathers experienced the communication of diagnosis in their fetus as a traumatic event. There was no correlation between type of malformation and trauma nor was there statistical difference between mother and father regarding the stressor.

CONCLUSION

Communication of diagnosis of a fetal anomaly can be a traumatic event and should be dealt with consequently. Given the therapeutic value of sharing traumatic experience such practice should be encouraged as part of the consultation process.

Pain, suffering, and trauma in labor and prevention of subsequent posttraumatic stress disorder

In this column, Kimmelin Hull, community manager of Science & Sensibility, Lamaze International's research blog, reprints and discusses a recent blog post series by acclaimed writer, lecturer, doula, and normal birth advocate Penny Simkin. Examined here is the fruitful dialog that ensued-including testimonies from blog readers about their own experiences with traumatic birth and subsequent posttraumatic stress disorder. Hull further highlights the impact traumatic birth has not only on the birthing woman but also on the labor team-including doulas and childbirth educators-and the implied need for debriefing processes for birth workers. Succinct tools for assessing a laboring woman's experience of pain versus suffering are offered by Simkin, along with Hull's added suggestions for application during the labor and birth process.

Health-Led Interventions in the Early Years to Enhance Infant and Maternal Mental Health: A Review of Reviews

BACKGROUND

  Increasing recognition of the importance of maternal mental health and early parenting in optimising the later mental health of the child has given rise to new ways of working during the perinatal period.

AIMS

  The objective of this review is to identify effective health-led interventions to support parents, parenting and the parent-infant relationship during the perinatal period,¹ and beyond.

METHOD

  A systematic search of key electronic databases was undertaken to identify secondary and primary sources of data addressing the research question. Twenty-four reviews addressed the effectiveness of interventions delivered during the postnatal period in promoting closeness and sensitive parenting, infant sensory and perceptual capabilities, and positive parenting, and in addressing infant regulatory problems, maternal mental health problems, and parent-infant relationship problems.

CONCLUSIONS

  A number of methods of working are recommended as part of a model of progressive-universalism beginning ante-natally and continuing through the first two post-natal years, and beyond. The implications for universal, targeted and specialist healthcare services are explored, alongside the role and contribution of CAMHS practitioners.

Management of post traumatic stress disorder after childbirth: a review

Prevalence and risk factors for the development of post traumatic stress disorder (PTSD) after childbirth is well described in the literature. However, its management and treatment has only begun to be investigated. The aim of this article is to describe the studies that examine the effects of interventions on PTSD after childbirth. MedLine, PILOTS, CINAHL and ISI Web of Science databases were systematically searched for randomised controlled trials, pilot studies and case studies using key words related to PTSD, childbirth, treatment and intervention. The reference lists of the retrieved articles were also used to supplement the search. A total of nine studies were retrieved. Seven studies that examined debriefing or counselling were identified; six randomised controlled trials and one pilot study. Also found were one case report describing the effects of cognitive behavioural therapy (CBT) on two women, and one pilot study of eye movement desensitisation and reprocessing (EMDR). Overall, there is limited evidence concerning the management of women with PTSD after childbirth. The results agree with the findings from the non-childbirth related literature: debriefing and counselling are inconclusively effective while CBT and EMDR may improve PTSD status but require investigation in controlled trials before conclusions could be drawn.

Stressful events, social support and coping strategies of primiparous women during the postpartum period: a qualitative study

OBJECTIVE

to identify problems and events perceived as stressful by primiparous mothers during the postpartum period, and to explore the social support and coping strategies they used to face these situations.

DESIGN

a qualitative study. Data were collected via semi-structured interviews and analysed using a content-analysis method.

SETTING

Geneva University Hospitals, Geneva, Switzerland from October 2006 to March 2007.

PARTICIPANTS

60 women interviewed six weeks after the birth at term of their first child.

FINDINGS

during the early postpartum period, interaction with caregivers was an important source of perceived stress. Upon returning home, the partner was considered as the primary source of social support, but the first need expressed was for material support. Breast feeding was perceived negatively by the new mothers, and this may be due to the difference between the actual problems encountered and the idealised expectations conveyed by prenatal information. Educational information dispensed by medical staff during the prenatal period was not put into practice during the postpartum period. Mothers expressed the need to be accompanied and counselled when problems arose and regretted the lack of long-term postpartum support.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

both the prenatal education and postpartum social support seem to mismatch women's needs and expectations. Concerted efforts are required by health professionals at the maternity unit and in the community to provide mothers with more adequate postpartum assistance.

Evaluation of changes in postnatal care using the "Parents' Postnatal Sense of Security" instrument and an assessment of the instrument's reliability and validity

BACKGROUND

A sense of security is important for experiences of parenthood in the early postpartum period. The objectives of this study were to evaluate two models of postnatal care using a questionnaire incorporating the Parents' Postpartum Sense of Security (PPSS) instrument and to test the validity of the PPSS instrument.

METHODS

Postal surveys were sent to 234 mothers who had experienced two different forms of postnatal care (study group and control group) and returned by 86.8%. These two groups of mothers were compared for total scores on the PPSS instrument. Demographic variables and mothers' opinions about care interventions were also compared and these variables were tested for correlations with the total PPSS score. A regression analysis was carried out to assess areas of midwifery care which might affect a sense of security. The internal consistency and concurrent validity of the instrument were tested for the total population.

RESULTS

there were no significant differences between the groups for scores on the PPSS instrument. A total of three variables predicted 26% of the variability on the PPSS scores for the study group and five variables predicted 37% of the variability in the control group. One variable was common to both: "The midwives on the postnatal ward paid attention to the mother as an individual". There were significant correlations between the total PPSS scores and scores for postpartum talks and visits to the breastfeeding clinic. There was also a significant correlation between the single question: "I felt secure during the first postpartum week" and the total PPSS score. Tests for internal consistency and concurrent validity were satisfactory.

CONCLUSION

The proposed new model of care neither improved nor impaired mothers' feelings of security the week following birth. Being seen as an individual by the midwife who provides postnatal care may be an important variable for mothers' sense of postnatal security. It is possible that postpartum talks may encourage the processing of childbirth experiences in a positive direction. Availability of breastfeeding support may also add to a sense of security postpartum. The PPSS instrument has shown acceptable reliability and validity.

A counselling model for postpartum women after distressing birth experiences

OBJECTIVE

to describe the development and application of a brief counselling intervention for women who have experienced a traumatic birth.

INTERVENTION

the birthing trauma counselling model reflecting women's need to establish a therapeutic connection with a midwife, talk about their birth experience and have their feelings validated. Gaps in understanding of events need explanation and explicit connections made between the event and subsequent emotions and behaviours. Developing a rational understanding of birthing events and how labour may have been managed differently assists women to revise their assumptions about maternity care and gain a sense of control. Fostering social support, reinforcing positive approaches to coping and exploring solutions to restoring self-confidence and reducing anxiety may help re-establish psychological equilibrium.

DISCUSSION AND CONCLUSION

the counselling intervention is consistent with trauma theory and draws on cognitive behavioural therapy principles. Midwives are well placed to provide counselling support to women experiencing birth-related distress. Further testing of the intervention in the clinical setting with a large sample is required.

Learning from experience: Using action research to discover consumer needs in post-seclusion debriefing

Approximately 16% of consumers are secluded during an inpatient admission. Despite the harmful psychological consequences resulting from the use of physical force, restraint, control, and temporary sequestration of therapeutic communication, there is little evidence of nursing practices to support consumers who are secluded. This paper will outline the findings from an action research project examining post-seclusion debriefing practice. A series of focus groups was undertaken with mental health nurses (MHN) and consumer consultants (CC) to investigate current practice, identify consumer/clinician preferences, and scope future practice possibilities. The findings suggest that CC need assistance in dealing with the negative feelings evoked by seclusion. MHN use a range of approaches for debriefing; however, these sometimes do not meet consumer preferences. MHN focus on explaining why seclusion happened and how to avoid it. While mitigation is a critical issue, CC want more emotional support from debriefing. MHN saw the possibility of using the debriefing to support consumers' transit from seclusion to high-dependency status and then to low-dependency status. Opinions raised regarding the potential for CC to have a role in debriefing were divided. The findings will be used to inform the development of a consumer debriefing training program for MHN and CC.

An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of an integrated multiple risk intervention, delivered mainly during pregnancy, in reducing such risks (cigarette smoking, environmental tobacco smoke exposure, depression, and intimate partner violence) postpartum.

METHODS

Data from this randomized controlled trial were collected prenatally and on average 10 weeks postpartum in six prenatal care sites in the District of Columbia. African Americans were screened, recruited, and randomly assigned to the behavioral intervention or usual care. Clinic-based, individually tailored counseling was delivered to intervention women. The outcome measures were number of risks reported postpartum and reduction of these risks between baseline and postpartum.

RESULTS

The intervention was effective in significantly reducing the number of risks reported in the postpartum period. In bivariate analyses, the intervention group was more successful in resolving all risks (47% compared with 35%, P=.007, number needed to treat=9, 95% confidence interval [CI] 5-31) and in resolving some risks (63% compared with 54%, P=.009, number needed to treat=11, 95% CI 7-43) as compared with the usual care group. In logistic regression analyses, women in the intervention group were more likely to resolve all risks (odds ratio 1.86, 95% CI 1.25-2.75, number needed to treat=7, 95% CI 4-19) and resolve at least one risk (odds ratio 1.60, 95% CI 1.15-2.22, number needed to treat=9, 95% CI 6-29).

CONCLUSION

An integrated multiple risk factor intervention addressing psychosocial and behavioral risks delivered mainly during pregnancy can have beneficial effects in risk reduction postpartum.

The costs of 'being with the woman': secondary traumatic stress in midwifery

OBJECTIVE

it is widely acknowledged that caring can cause emotional suffering in health-care professionals. The concepts of compassion fatigue, post-traumatic stress disorder and secondary traumatic stress are used to describe the potential consequences of caring for people who are or have experienced trauma. Empathy between the professional and patient or client is a key feature in the development of secondary traumatic stress. The aim of this paper is to contribute to the conceptual development of theory about dynamics in the midwife-woman relationship in the context of traumatic birth events, and to stimulate debate and research into the potential for traumatic stress in midwives who provide care in and through relationships with women.

METHOD

the relevant literature addressing secondary traumatic stress in health-care professionals was reviewed.

FINDINGS

it is argued that the high degree of empathic identification which characterises the midwife-woman relationship in midwifery practice places midwives at risk of experiencing secondary traumatic stress when caring for women experiencing traumatic birth. It is suggested that this has harmful consequences for midwives' own mental health and for their capacity to provide care in their relationships with women, threatening the distinct nature of midwifery care.

CONCLUSIONS

opportunities for research to establish the existence of this phenomenon, and the potential implications for midwifery practice are identified.

What psychosocial well-being in the postnatal period means to midwives

OBJECTIVE

to explore midwives' views of psychosocial well-being in the postnatal period.

DESIGN

qualitative study using focus-group interviews conducted in 1999.

SETTING

two community health centres and a school of nursing and midwifery in Scotland.

PARTICIPANTS

a convenience sample of community and student midwives.

ANALYSIS

thematic analysis was undertaken through the identification of codes, categories and themes.

FINDINGS

the categories were generated from the interview questions: 'the meaning midwives give to women's psychosocial well-being', 'midwives' assessment of women's well-being', and 'midwives views of worrying behaviours' displayed by women. From the first two categories, themes of 'coping', 'expectations', 'observation and communication skills', 'labour debriefing', and 'previous contact with women' emerged. Midwives assessed coping and unmet expectations through a range of communication and observational skills, including the use of a form of labour debriefing. Midwives who knew women during their pregnancy thought that they were able to assess coping and expectations better in the postnatal period. The midwives tended to describe women using stereotypical categories. From the third category, 'worrying behaviours', three themes emerged; 'extreme or obsessive behaviours about self, the baby or house' 'wanting to detain you' and 'quiet women'.

CONCLUSIONS

the meaning midwives give to psychosocial well-being includes a complex interplay between midwives' views of psychosocial well-being and their assessment of it. The importance midwives give to knowing women in pregnancy has implications for the ongoing debate about the provision of continuity of carer. Midwives used a range of techniques to elicit accurate information, to confirm problems or be reassured that all was well. Views based on stereotypical generalisations should be challenged.

[Postpartum depression: we know the risks, can it be prevented?]

In the past 20 years, there has been increasing recognition that for some women, pregnancy may be burdened with mood problems, in particular depression, that may impact both mother and child. With identification of risk factors for postpartum depression and a growing knowledge about a biologic vulnerability for mood change following delivery, research has accumulated on attempts to prevent postpartum depression using various psychosocial, psychopharmacologic, and hormonal strategies. The majority of psychosocial and hormonal strategies have shown little effect on postpartum depression. Notwithstanding, results from preliminary trials of interpersonal therapy, cognitive-behavioural therapy, and antidepressants indicate that these strategies may be of benefit. Information on prevention of postpartum depression using dietary supplements is sparse and the available evidence is inconclusive. Although a few studies show promising results, more rigorous trials are required. The abounding negative evidence in the literature indicates that postpartum depression cannot be easily prevented, yet.

Randomised controlled trial of community debriefing following operative delivery

OBJECTIVE

The aim of this study was to determine if two debriefing sessions following an operative delivery could reduce a woman's fear of future childbirth.

DESIGN

Prospective randomised controlled trial (RCT) with two arms comparing debriefing, aimed to reduce fear of future childbirth, with standard care after birth.

SETTING

District General Hospital with 2500 deliveries per year.

SAMPLE

Three hundred and nineteen mothers who delivered a first child by operative delivery (i.e. forceps, vacuum or emergency caesarean section). The study took place at Huddersfield Royal Infirmary, from January 2002 to July 2003.

METHODS

Debriefing by community midwives specifically trained in postpartum debriefing at 10 days and 10 weeks.

MAIN OUTCOME MEASURE

Fear of childbirth was assessed using the Wijma Delivery Expectancy Scale (WDEQ). WDEQ scores were measured 10 days, 10 weeks and 20 weeks following delivery.

RESULTS

Fear of childbirth as measured by the WDEQ was lower throughout the study for the debriefing group. However, it never reached statistical significance in the short term [10 days debriefing = 94.5, control = 97.5 (P= 0.295), 10 weeks debriefing = 92.0, control = 97.9 (P= 0.076), 20 weeks debriefing = 90.9, control = 97.4 (P= 0.057)].

CONCLUSION

This study shows in the short term there was no significant difference in the WDEQ fear of childbirth scores. The debriefing group were showing a tendency for lower scores. Long term follow up of these cases may be more relevant.

An exploratory mixed-methods study of Scottish midwives' understandings and perceptions of clinical near misses in maternity care

OBJECTIVE

adverse outcomes and near misses are believed to share many characteristics in terms of clinical situations and care management problems. Little is documented concerning what prevents adverse outcomes from happening once the 'accident trajectory' begins. This two-stage pilot study set out to investigate midwives' understandings and recollections of clinical near misses.

DESIGN

anonymous self-completion questionnaire and follow-up group interviews.

SETTING/PARTICIPANTS

clinically based midwives working in four maternity units in Scotland (questionnaire [n = 34]; interviews [n = 26]).

FINDINGS

despite a low response rate to the questionnaire, the cited examples seem to confirm that near misses and adverse outcomes follow essentially similar routes until the former are halted by a saving intervention. Dangerous situations are created by heavy workloads, and are aggravated by sub-optimal skill-mix, poor communication and individuals making mistakes or not following accepted procedures. Overwhelmingly, what prevents this situation from resulting in an adverse outcome is an intervention by another practitioner--often reported to be by chance and not design. In the interviews, these situations were discussed with reference to unit culture, the causes of errors and near misses, helping to prevent mistakes, the consequences of near misses and staff confiding in one another.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

this limited study reaffirms the view that clinical near misses have the same origins as actual poor outcomes. Practitioners need to be able to discuss clinical and operational matters openly with colleagues. Although the 'blame culture' was reported to be less prevalent when things go wrong, not all midwives feel comfortable about discussing incidents or near misses. This exploratory study makes no claim to encapsulate this complex and sensitive subject. Further detailed research into the nature and extent of near misses is required. Identifying what prevents a poor outcome from happening may be a valuable clinical resource.

Effectiveness of a counseling intervention after a traumatic childbirth: a randomized controlled trial

Adverse childbirth experiences can evoke fear and overwhelming anxiety for some women and precipitate posttraumatic stress disorder. The objective of this study was to assess a midwife-led brief counseling intervention for postpartum women at risk of developing psychological trauma symptoms.

METHOD

Of 348 women screened for trauma symptoms, 103 met inclusion criteria and were randomized into an intervention (n = 50) or a control (n = 53) group. The intervention group received face-to-face counseling within 72 hours of birth and again via telephone at 4 to 6 weeks postpartum. Main outcome measures were posttraumatic stress symptoms, depression, self-blame, and confidence about a future pregnancy.

RESULTS

At 3-month follow-up, intervention group women reported decreased trauma symptoms, low relative risk of depression, low relative risk of stress, and low feelings of self-blame. Confidence about a future pregnancy was higher for these women than for control group women. Three intervention group women compared with 9 control group women met the diagnostic criteria for posttraumatic stress disorder at 3 months postpartum, but this result was not statistically significant.

DISCUSSION

A high prevalence of postpartum depression and trauma symptoms occurred after childbirth. Although most women improved over time, the intervention markedly affected participants' trajectory toward recovery compared with women who did not receive counseling.

CONCLUSIONS

A brief, midwife-led counseling intervention for women who report a distressing birth experience was effective in reducing symptoms of trauma, depression, stress, and feelings of self-blame. The intervention is within the scope of midwifery practice, caused no harm to participants, was perceived as helpful, and enhanced women's confidence about a future pregnancy.

Group counseling for mothers after emergency cesarean section: a randomized controlled trial of intervention

BACKGROUND

An emergency cesarean section is often a traumatic experience for women, and can be associated with postnatal depression and posttraumatic stress. Various types of interventions have been tested to prevent such consequences. The purpose of this study was to test a model of group counseling for mothers after emergency cesarean section, and to examine its possible effects.

METHOD

After undergoing an emergency cesarean section, 162 Swedish-speaking women were randomized to group counseling or the control group. The participation rate was 75 percent. The counseling consisted of 2 sessions, conducted at about 2 months postpartum; 72 percent of the women randomized to the counseling group actually attended the sessions. At 6 months postpartum, all study participants completed a postal questionnaire (response rates were 92% in the counseling group and 89% in the control group).

RESULTS

No difference between the groups was found in terms of the level of fear after childbirth, symptoms of posttraumatic stress, or postnatal depression at 6 months after the emergency cesarean. The group counseling was much appreciated by the participating women, some of whose experiences are reported in this paper.

CONCLUSION

Group counseling for mothers after emergency cesarean section did not influence their views on the recent delivery or prevent symptoms of posttraumatic stress or postnatal depression. It was, however, appreciated and did no harm. In future studies, other outcomes should be measured.

Content and processes of postpartum counseling after a distressing birth experience: a review

BACKGROUND

A distressing birth experience can produce debilitating symptoms of psychological trauma; however, little is known about the content and processes of counseling interventions to relieve trauma symptoms. This review identifies and examines common content and processes of postpartum counseling interventions to address trauma symptoms following childbirth.

METHOD

A search of major databases (Cinahl 1982-2003; Cochrane 2003; Embase; Proquest; Psychlit; Pubmed/Medline 1966-2003; Sociofile) was conducted, using combinations of the key words of "childbirth,""postpartum,""posttraumatic stress disorder,""anxiety,""trauma,""stress,""debriefing," and "counselling" or "counseling." Identified content and processes were clustered through a thematic analysis.

RESULTS

Nineteen publications were retrieved. Counseling strategies provided women with opportunities to talk about their birth experience, express feelings about what happened, have questions answered, address gaps in knowledge or understanding of events, connect the event with emotions and behavior, talk about future pregnancies, and explore existential issues.

CONCLUSIONS

Descriptions of postpartum counseling and debriefing are generalized and nonspecific; they provide minimal direction for postpartum counseling models, lack necessary detail for replication, may require psychotherapeutic training and therefore be unsuitable for use by caregivers, and are often based on opinion with little empirical evaluation. Few studies have tested specific counseling interventions on a range of maternal outcomes. Further research is needed to develop counseling models for use by health professionals with women who report a distressing birth experience.

Post-Traumatic Stress Disorder Due to Childbirth

BACKGROUND

Childbirth qualifies as an extreme traumatic stressor that can result in post-traumatic stress disorder. The reported prevalence of post-traumatic stress disorder after childbirth ranges from 1.5% to 6%.

OBJECTIVE

The aim of this phenomenologic study was to describe the essence of mothers' experiences of post-traumatic stress disorder after childbirth.

METHODS

The qualitative research design used for this study was descriptive phenomenology. The main recruitment approach was via the Internet through the help of Trauma and Birth Stress, a charitable trust in New Zealand. Purposive sampling was used and resulted in 38 mothers participating from the countries of New Zealand, the United States, Australia, and the United Kingdom. The participants were asked to describe their experiences with post-traumatic stress disorder after childbirth. Their stories were analyzed using Colaizzi's method of data analysis.

RESULTS

Mothers with post-traumatic stress disorder attributable to childbirth struggle to survive each day while battling terrifying nightmares and flashbacks of the birth, anger, anxiety, depression, and painful isolation from the world of motherhood.

CONCLUSIONS

This glimpse into the lives of mothers with post-traumatic stress disorder attributable to childbirth provides an impetus to increase research efforts in this neglected area.

Comparative levels of psychological distress, stress symptoms, depression and anxiety after childbirth--a prospective population-based study of mothers and fathers

OBJECTIVE

To compare maternal and paternal psychological responses following birth of a healthy baby; and to explore predictors of parental psychological distress.

DESIGN

A prospective, longitudinal, population-based cohort study.

SETTING

A Norwegian district general hospital.

POPULATION

One hundred and twenty-seven mothers and 122 fathers were included.

METHODS

Eligible consenting parents were enrolled. The assessments, which were performed zero to four days after birth, at six weeks and at six months, included General Health Questionnaire-28 (GHQ-28), State Anxiety Inventory and Impact of Event Scale. The response rates at the three occasions were 97%, 85% and 71%.

MAIN OUTCOME MEASURES

Symptoms of intrusion, avoidance, arousal and psychological distress including anxiety, depression, social dysfunction and somatisation.

RESULTS

Clinically important psychological distress was reported by 37% of the mothers and 13% of the fathers a few days after childbirth (P < 0.001). Severe intrusive stress symptoms were reported by 9% and 2% of mothers and fathers, respectively (P = 0.002). Level of intrusive stress was the outcome that differed most clearly between mothers and fathers at all three points of time. Being a single parent, multiparity and a previous traumatic birth were significant independent predictors of acute maternal psychological distress. After six weeks and six months, the level of psychological distress including symptoms of depression fell to levels found in the general population.

CONCLUSIONS

Childbirth does not seem to trigger long term psychological distress in most parents. Clinically important psychological distress occurred more frequently in mothers than in fathers. Acute maternal psychological distress was predicted by being a single parent, being multiparous, and having a previous traumatic birth.