In a recent study posted to the medRxiv* preprint server, a group of researchers systematically reviewed and quantitatively assessed clinical trials from December 1998 to December 2022 on preventing Childbirth-Related Post-Traumatic Stress Disorder (CB-PTSD), identifying optimal interventions, timings, and target populations.

Study: A Systematic Review of Interventions for Prevention and Treatment of Post-Traumatic Stress Disorder Following Childbirth. Image Credit: christinarosepix/Shutterstock.com

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Background 

About one-third of women experience high stress during childbirth, sometimes leading to CB-PTSD. The United States (U.S.) has high rates of severe maternal morbidity, with its numbers among the highest in Western nations.

Around 5-6% of postpartum women, equating to 240,000 in the U.S. annually, suffer from CB-PTSD, which can severely impact maternal-child bonding and increase infant behavioral and health issues. CB-PTSD has distinctive characteristics that make early intervention plausible.

While childbirth is predictable, the immediate aftermath can be critical to address potential trauma. Recent reviews suggest trauma-focused early interventions show promise, but more research is essential to finalize guidelines.

About the study

To be considered for the present systematic review, studies underwent an independent evaluation based on certain criteria. They needed to be interventional, focus on CB-PTSD prevention or treatment, and include outcome measures assessing CB-PTSD symptoms or diagnosis.

Certain exclusions were made, such as duplicate studies and those involving mothers who had only experienced stillbirths. This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines, with the protocol on the International Prospective Register of Systematic Reviews (PROSPERO).

A search was executed across multiple databases, including PubMed and Embase, using specific keywords related to childbirth PTSD and its treatment, and published reviews on CB-PTSD therapies were also consulted. 

From December 1998 to December 2022, 33 studies met the inclusion criteria and underwent review following the PRISMA workflow process. For data extraction, two reviewers utilized an excel-based form to capture vital study elements, from sample characteristics to outcome measures. The focus was on the treatment effects concerning CB-PTSD symptoms and related conditions.

The reviewers used the Downs and Black checklist, a crucial tool for assessing the quality of non-randomized and randomized healthcare interventions. This checklist provides a comprehensive rating scale addressing various study qualities like external and internal validity.

Each element in the checklist has a score, with the maximum score indicating the study's overall quality. The two reviewers independently scored each study, achieving a high inter-rater reliability of 91%, and later engaged in discussions to resolve any scoring discrepancies, ensuring complete agreement.

Study results 

Out of 33 studies analyzed, 25 were randomized controlled trials (RCTs), and 8 were non-RCTs. These trials spanned across different prevention stages: three were primary prevention during pregnancy; 19 were secondary preventions post-childbirth but not exceeding one month; and 11 were tertiary preventions after one month post-childbirth, specifically for confirmed or probable CB-PTSD cases.

Most studies, 31 out of 33, focused on psychologically oriented therapies, including trauma-focused interventions, mother-infant dyad therapies, counseling, visual biofeedback, and visual-spatial cognitive tasks, whereas the remaining two focused on educational interventions.

CB-PTSD symptoms were primarily assessed through patient self-administered questionnaires in 30 trials, while clinician evaluations were conducted in three. Typically, the outcomes were measured within the first six months post-intervention, with longer effects assessed in six trials.

Regarding specifics, psychological debriefing postpartum was explored in five trials but showed inconsistent results. Trauma-focused (TF) crisis intervention showed short-term benefits, especially post-premature deliveries.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) demonstrated positive results when delivered during an infant's hospitalization but mixed results for later interventions. Eye Movement Desensitization and Reprocessing (EMDR) yielded positive outcomes for immediate and longer post-childbirth interventions.

Trauma-Focused Expressive Writing (TF-EW) showcased benefits when applied immediately after childbirth and in subsequent weeks and months, particularly for those at higher risk of CB-PTSD.

For postpartum women facing CB-PTSD, psychological counseling, primarily midwife-led, offers a structured approach emphasizing therapeutic relationships, emotional expression, and baby care.

Multiple RCTs assessed its efficacy, rating the quality from fair to good. Individual sessions of post-traumatic childbirth reduced CB-PTSD and postpartum depression (PPD) symptoms, bolstering confidence in future pregnancies. Intense early postpartum sessions enhanced maternal-infant bonds.

Conversely, group-format counseling in subsequent months post-trauma showed limited promise. Interventions emphasizing mother-infant interactions, like immediate post-birth skin-to-skin contact, decreased CB-PTSD symptoms.

Observational sessions after preterm births increased maternal sensitivity and decreased stress. Some strategies, however, lacked clear benefits.

Additional interventions included visual biofeedback during labor, linking a mother's efforts to the baby's movements, fostering maternal-newborn bonding, and reducing later CB-PTSD symptoms.

A Tetris-based approach aimed at reducing traumatic visual memories showed mixed results, reducing intrusive memories but not broader CB-PTSD impacts. Educational interventions during pregnancy, led by midwives and nurses, prepared mothers for childbirth and parenting.

These mostly decreased childbirth fear, and CB-PTSD symptoms in non-high-risk women, but postpartum self-help materials for traumatic childbirth were ineffective in addressing CB-PTSD symptoms.

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Written by

Vijay Kumar Malesu

Vijay holds a Ph.D. in Biotechnology and possesses a deep passion for microbiology. His academic journey has allowed him to delve deeper into understanding the intricate world of microorganisms. Through his research and studies, he has gained expertise in various aspects of microbiology, which includes microbial genetics, microbial physiology, and microbial ecology. Vijay has six years of scientific research experience at renowned research institutes such as the Indian Council for Agricultural Research and KIIT University. He has worked on diverse projects in microbiology, biopolymers, and drug delivery. His contributions to these areas have provided him with a comprehensive understanding of the subject matter and the ability to tackle complex research challenges.