Debriefing interventions for the prevention of psychological trauma in women following childbirth
Abstract
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 The reference lists of all included studies were checked for additional published reports and citations of unpublished research.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.
PICOs
Plain language summary
Debriefing interventions for the prevention of psychological trauma in women following childbirth
Why is this review important?
Having a baby is a complex life event. While many women view their experiences of giving birth as very positive, childbirth can sometimes be experienced as a traumatic event. If a birth is experienced as traumatic, it could have a negative impact on a woman's long‐term emotional well‐being. Relationships between mother and child may be affected, as can the women's relationships with other family members. One intervention that is commonly used with the aim of reducing psychological trauma (that is anxiety, trauma or depressive symptoms) and preventing the development of post‐traumatic stress disorder following birth is debriefing. Debriefing includes a variety of post‐birth discussions that provide women an opportunity to talk about their birth experience. In this review we examined the evidence for debriefing as a preventative intervention for psychological trauma following childbirth.
Who may be interested in this review?
‐ Women who have recently given birth, their families and friends.
‐ Midwives, health visitors and other medical professionals who have close contact with women who are pregnant or have just given birth.
What questions does this review aim to answer?
Is debriefing more or less effective than standard postnatal care in preventing psychological trauma among women who have recently given birth.
Which studies were included in the review?
We searched databases to find all studies (specifically randomised controlled trials) published before 4 March 2015 that investigated debriefing for the prevention of psychological trauma in women following childbirth. We included seven studies with a total of 3596 women. The studies were published between 1998 and 2005 and all were conducted in high‐income countries (UK, Australia and Sweden).
What does the evidence from the review tell us?
There was no evidence of a difference between debriefing and standard postnatal care in preventing psychological trauma up to three months post‐birth or at three to six months after birth. We did not find any information to tell us whether debriefing led to women leaving the studies early. The quality of the evidence presented in the included studies was generally low. There were a number of limitations in the way the studies were designed (for example some had small sample sizes) and reported (for example incomplete data were presented). Further well‐designed studies are needed for us to more clearly understand whether debriefing can minimise the psychological impact of a traumatic birth experience and ensure that it poses no harmful effects.
