Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

A midwife-led debriefing session after operative childbirth did not reduce postpartum depression

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ACP J Club. 2001 May-June;134:86. doi:10.7326/ACPJC-2001-134-3-086


Source Citation

Small R, Lumley J, Donohue L, Potter A, Waldenström U. Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth. BMJ. 2000 Oct 28;321:1043-7. [PubMed ID: 11053173]


Abstract

Question

In women who give birth by cesarean section, forceps, or vacuum extraction, is a midwife-led debriefing session better than standard care for reducing maternal depression at 6 months postpartum?

Design

Randomized (allocation concealed*), unblinded,* controlled trial with 6-month follow-up.

Setting

A large maternity teaching hospital in Melbourne, Victoria, Australia.

Patients

1041 women who had operative deliveries. Exclusion criteria were women with stillbirths or babies weighing < 1500 g, insufficient fluency in English, or ill mothers or ill babies. Follow-up was 88% (62% were 25 to 34 y of age, 27% were ≥ 35 y of age).

Intervention

Women were allocated to debriefing (n = 520) or standard care (n = 521). Debriefing occurred before women were discharged from the hospital. 1 of 2 research midwives met with each woman for up to 1 hour to talk about the woman's labor, birth, and postdelivery events and experiences. The content of the discussion was determined by the woman's experiences and concerns.

Main outcome measures

Maternal depression (score ≥ 13 on the Edinburgh Postnatal Depression Scale) and overall maternal health status (SF-36) at 6 months. These scales were assessed by a postal questionnaire. A secondary outcome was satisfaction with care.

Main results

Debriefing and standard care did not differ significantly in rates of postpartum depression at 6 months (Table). Debriefing led to poorer health status on 7 of 8 SF-36 scales, but the difference was only statistically significant for role functioning (emotional) (Table). Groups did not differ for satisfaction with care. The study had > 80% power to detect a 33% difference for depression and a 10% difference in satisfaction with care.

Conclusion

In women who gave birth by cesarean section, forceps, or vacuum extraction, midwife-led debriefing did not reduce depression and led to poorer emotional role functioning.

*See Glossary.

Source of funding: Australian Commonwealth Department of Health, Housing, and Community Services.

For correspondence: Ms. R. Small, Centre for the Study of Mothers' and Children's Health, School of Public Health, La Trobe University, Carlton, Victoria 3053, Australia. FAX 61-3-8341-8555.


Table. A midwife-led debriefing session vs standard care after operative childbirth†

Outcomes at 6 mo Debriefing Standard care RRI (95% CI) NNH
Depression (≥ 13 on EPDS) 17% 14% 20% (-11 to 62) Not significant
Mean difference (CI)
SF-36 subscale-role functioning (emotional) mean scores 73.3 79.0 5.66 (0.87 to 10.5)

†EPDS = Edinburgh Postnatal Depression Scale. Other abbreviations defined in Glossary; RRI, NNH, mean difference, and CI calculated from data in article.


Commentary

The study by Small and colleagues clearly shows that a brief counseling session is not effective for alleviating the distress engendered by an operative delivery. The study methods were impeccable, the population was clearly in need, the intervention was expertly carried out, and the outcomes studied were substantive. In addition, similar interventions in a variety of post-traumatic situations have also been shown to be ineffective or counterproductive (1). It is tempting to throw up one's hands and conclude that nothing can be done, but these women need help and appreciate the process; 94% of the women found the debriefing session helpful. Perhaps the intervention was both too little and too late. Support during labor results in a substantial reduction in the need for operative delivery and has a direct preventive effect on postpartum depression (2).

Regardless of its cause, depression may be alleviated by enhanced postpartum professional or social support, or both (3). The underlying message of the study by Small and colleagues is not to withdraw support but to provide the needed support more effectively, earlier, and for a longer period.

Murray Enkin, MD
McMaster University
Hamilton, Ontario, Canada


References

1. Wessely S, Bisson J. Brief psychological interventions (“debriefing”) for trauma-related symptoms and prevention of post traumatic stress disorder. Cochrane Database Syst Rev. 2001;(1):CD00560.

2. Hodnett ED. Caregiver support for women during childbirth. Cochrane Database Syst Rev. 2001;(1):CD000199.

3. Ray KL, Hodnett ED. Caregiver support for postpartum depression. Cochrane Database Syst Rev. 2001;(1):CD000946.