POSTNATAL DEBRIEFING STILL VALUED BY WOMEN
Providing debriefing for women in the postnatal period is believed by many midwives to help women to adjust to their childbirth experiences, and to help reduce postnatal psychological morbidity. The evidence base is equivocal in relation to the efficacy of these kinds of interventions, which are typically delivered by midwives in clinical practice.
This essay will review several pieces of research relating to postnatal debriefing associated with the psychological distress and potential post traumatic stress disorder associated with childbirth. It will look at the quality of evidence available and discuss some of the parameters of the arguments surrounding the provision of postnatal debriefing, listening and counselling services. It will also make recommendations for practice in relation to this kind of provision, and in relation to future research.
Lavender and Walkinshaw (1998) carried out a randomised trial of a postnatal ‘debriefing’ service provided by midwives, to see what effect it had on psychological morbidity after childbirth. The authors comprise one midwife and one obstetrician, and the midwife has a postgraduate degree, suggestive that they have the skills to carry out and report on such a study. Using a randomised trial design is aimed at filling an apparent gap in the research at the time of the study, in relation to this area of practice (Lavender and Walkinshaw, 1998). This study was carried out “in a regional teaching hospital in northwest England, and used a sample of “one hundred and twenty postnatal primigravidas”, who were “allocated by sealed envelopes to receive the debriefing intervention (n 4 56) or not (n 4 58).” (Lavender and Walkinshaw, 1998 p 215). The study involved the collection of baseline intrapartum and demographic information in order to assess a wide variety of variables in the study (Lavender and Walkinshaw, 1998).
The intervention is described as follows:
“ Women randomised to the intervention participated in an interactive interview in which they spent as much time as necessary discussing their labour, asking questions, and exploring their feelings. One research midwife, who had received no formal training in counselling, conducted the interviews, which lasted between 30 and 120 minutes, the duration being guided by the needs of the respondent. Hospital notes were available throughout the interview so that direct questions could be answered. No interview schedule was defined, since the interviews were respondent led.” (Lavender and Walkinshaw, 1998)
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This approach raises several points. To being with, it is positive that there is such transparency in explaining the intervention, even if the intervention is brief, because it allows the reader to understand the nature, it aids replication, and it demonstrates the lack of specialist knowledge required to perform the intervention. Secondly, it shows that a research midwife, who was not a counsellor, was carrying out the intervention. And thirdly, it demonstrates a woman-focused, midwifery-oriented approach, in that the interviews were respondent led and the length was not limited. Such an approach reflects midwifery philosophies which makes the article useful for midwifery practice.
Lavender and Walkinshaw (1998) used an established data collection instrument,
the Hospital Anxiety and Depression (HAD) scale, which was administered by postal
questionnaire 3 weeks after delivery. Using an established data collection instrument adds strength to the study, but there is a small amount of unreliability about postal questionnaires, because there is never any guarantee that they are filled out by the person they are sent to. Using the pre-tested scale allowed the authors to compare the proportion of women in each group with anxiety and depression scores of more than 10 points, using odds ratios and 95% confidence intervals, both of which are acceptable statistical applications for these data. The 95% response rate ensured a good sample size (Lavender and Walkinsahw, 1998), although the study would have had even more statistical significance if it could have been carried out across more than one site. The benefits of this intervention were established by the study, but the authors raise some concerns, including concern at the high levels of morbidity detected, and question whether using the chosen scale was appropriate for measuring psychological morbidity after childbirth (normal or abnormal) (Lavender and Walkinshaw, 1998). This study is limited now by its age, and by being superceded by more recent studies.
Kershaw et al (2005) carried out a prospective randomised controlled trail with two arms, which compared debriefing methods after birth which were aimed at reducing fear of future childbirth. As can be seen, this studied a more specific intervention, in relation to a very specific outcome, rather than measuring psychological morbidity per se. This would make it more applicable to specific aspects of practice. This study was also carried out in one site, and the authors provide details of the hospital site, which this author would question due to the issue of confidentiality. Kershaw et al (2005) focused on mothers whose first birth was an operative delivery, and gained ethical approval. More details about the ethics of this study would have enhanced its quality. Kershaw et al (2005) provide their inclusion and exclusion criteria, but do not discuss controlling for other variables. They also use a pre-established measurement tool to assess the fear of childbirth experienced by the study participants (Kershaw et al, 2005). They do subsequently present demographic information, and they use a range of suitable statistical tests, explaining the significance of these, which makes it easier for the novice reader to begin to assess the quality of the data analysis. This again was a debriefing intervention carried out by midwives in the postnatal period (Kershaw et al, 2005).
However, unlike the previous study, this one differed because the debriefing was held on two separate occasions, and sessions were held at home (Kershaw et al, 2005). Another significant element of this study was that the midwives involved received training in critical incident stress debriefing (Kershaw et al, 2005). The authors justify their study as follows:
“ In this study fear of childbirth and post-traumatic stress were measured rather than maternal depression and general health. It was decided not to measure maternal depression as research has
suggested this is frequently associated with factors not related to childbirth. Women were allowed sufficient time to debrief, sessions lasted up to an hour and a half.” (Kershaw et al, 1508).
This shows some strengths, including a focus on specific psychological features, rather than on general health and depression, which can be difficult to assess. Although the authors state women were allowed sufficient time for the session, this study does not reflect the kind of midwifery philosophy that the Lavender and Walkinshaw (1998) study did. The findings from this study do not support the use of this particular intervention in this particular population.
“The findings of this study demonstrated in the short term no significant difference in the WDEQ fear of childbirth scores and IES emotional distress scores. These findings show community-led debriefing is not proven to be of any value in reducing women’s fear of childbirth following an operative
delivery.” (Kershaw et al, 2005 p 1508).
However, this study may not be the last word on this kind of intervention, and there are limitations, including the focus only on women who had operative deliveries, focusing on one site, and in the intervention itself. Maybe the nature of the intervention, and the training provided for midwives, was limited. The authors agree that a longer-term evaluation might show different results (Kershaw et al, 2005). It might be that the data collection tool was inappropriate, as with the previous study. However, this study, as with the previous one, does establish the usefulness and facility of midwives providing postnatal support of this kind. Kershaw et al (2005) show that midwives identified those women who would be needing debriefing, but this author would argue that midwives are not experts in mental health, and limiting debriefing to those identified by midwives as at higher risk might miss important cases. Reading between the lines of this study seems to imply that this intervention is valued by midwives and by patients, despite the findings of the statistical analysis.
Small et al (2000) carried out a randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth, again, focusing on women who are viewed as potentially at higher risk of mental health morbidity postnatally. This study was carried out in a large maternity teaching hospital in Melbourne, Australia, unlike the previous two studies, which were carried out in the UK. Small et al (2000) had a sample of 1041 women who had given birth by either caesarean section (n = 624) , by assisted vaginal delivery using forceps (n = 353) or vacuum extraction (n = 64), and these women were randomised to the intervention group or the control group (Small et al, 2000). The sample size was statistically calculated for significance, which is a strength of the study. The methodology is clear and the randomisation process described. The intervention “provided women with an opportunity to discuss their labour, birth, and postÂdelivery events and experiences” (Small et al, 2000 p 1044). Although there is a woman-centred focus in this study, only 1 hour maximum was allowed for the discussion, which this author would suggest is a severe limitation of this intervention in relation to woman-centred debriefing. The midwives were not trained but described as experienced and skilled. The main outcome measures were “maternal depression (score >13 on the Edinburgh postnatal depression scale) and overall health status (comparison of mean scores on SFÂ36 subscales) measured by postal questionnaire at six months postpartum” (Small et al, 2000 p 1044). Again, established scales are being used to lend strength to the study.
Small et al (2000) found that “more women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum care (81 (17%) v 65 (14%)), although this difference was not significant (odds ratio = 1.24, 95% confidence interval 0.87 to 1.77)” and “they were also more likely to report that depression had been a problem for them since the birth, but the difference was not significant (123 (28%) v 94 (22%); odds ratio = 1.37, 1.00 to 1.86).” (p 1043). According to this study, the authors demonstrated that midwife led debriefing following operative births was not only not effective in reducing maternal morbidity (in particular, psychological morbidity), at the six month point after delivery, but that it may have been a contributing factor to emotional health issues for certain women (Small et al, 2000). This author would suggest that it might be the nature of the intervention that is the issue here, because it was provided in hospital, soon after birth, and may not have been particularly woman-centred. Cultural differences between Australian women and UK women cannot be ruled out; neither can cultural differences in models of care and practice.
Priest et al (2003) carried out a randomised single-blind controlled trial, stratified for parity and delivery mode, to test whether critical incident stress debriefing after childbirth reduces the incidence of postnatal psychological disorders, also in Australia, in two maternity hospitals. They had a large enough sample size, consisting of 1745 women who delivered healthy term infants between a specificed time period, with 75 allocated to the intervention group and 870 to control group (Priest et al, 2003). Again, the study design is transparent, and the randomisation process clear. As with the previous study by Small et al (2000), the intervention was carried out soon after delivery, but this intervention consisted of an individual, standardised debriefing session based on the principles of critical incident stress debriefing. The intervention is described briefly, and it is stated that the midwives were trained in the intervention (Priest et al, 2003). However, the intervention itself and the training is not really described in great detail, which affects replication of the study. The intervention is based on theories which are not specifically developed for childbirth trauma, but that have been adapted, and this may be a weakness. As with the other studies, recognised outcome measures are used.
Priest et al (2003) found that “there were no significant differences between control and intervention groups in scores on Impact of Events or Edinburgh Postnatal Depression Scales at 2, 6 or 12 months postpartum, or in proportions of women who met diagnostic criteria for a stress disorder (intervention, 0.6% v control, 0.8%; P = 0.58) or major or minor depression (intervention, 17.8% v control, 18.2%; relative risk [95% CI], 0.99 [0.87–1.11]) during the postpartum year. Nor were there differences in median time to onset of depression (intervention, 6 [interquartile range, 4–9] weeks v control, 4 [3–8] weeks; P = 0.84), or duration of depression (intervention, 24 [12–46] weeks v control, 22 [10–52] weeks; P=0.98).” (p 544).
This leads to the conclusion that this single session of midwife led, specific debriefing was ineffective as a means of prevention of postnatal psychological disorders (Priest et al, 2003). While the authors conclude that the intervention had no ill effects (Priest et al, 2003), this author finds these findings significant in their lack of support for the intervention, and would suggest, again, that it may be the nature of the intervention that is leading to these kinds of results.
Gamble et al (2005) carried out a randomised controlled trial to assess the effectiveness of a counselling intervention after a traumatic childbirth, based on a midwife-led brief counselling intervention for women deemed at risk of developing symptoms of psychological symptoms postnatally. This was a smaller study group, with only 50 in the intervention group and 53 in the control group, and the intervention was also provided as face to face counselling within 72 hours of birth, as with the previous study, but also had a telephone counselling session at between four and six weeks postnatally (Gamble et al, 2005). The allocation/randomisation process is described, but the midwife was not blind to the randomisation, which may represent a potential source of bias. Established data collection scales were used as with all the previous studies: “Edinburgh Postnatal Depression Scale (EPDS) , Depression Anxiety and Stress Scale-21 (DASS-21) , and Maternity Social Support Scale (MSSS)” (Gamble et al, 2005 p 13). Gamble et al (2005) measured the following outcome measures: posttraumatic stress symptoms, depression, self-blame, and confidence about a future pregnancy. Gamble et al (2005) provide great detail about the underpinnings of the therapeutic intervention, and there is a midwifery/woman-centred focus to the intervention (and, by association, to the study). Gamble et al (2005) found their intervention to be effective in reducing symptoms of trauma, depression, stress, and feelings of self-blame.
All of these studies fall within the scope of good standards of evidence for practice, but find marked differences between studies in relation to efficacy and non-efficacy of interventions. There may be a number of reasons for this. Only one study suggests potential negative effects of this kind of intervention, but this was not conclusive and warranted further investigation. However, the literature around this subject does seem to predominantly suggest that such interventions are useful for women following birth. Axe (2000) suggests that women can use such support to help them cope with the difference between their expectations and experiences of birth. Robinson (1999) argues for the increasing occurrence of post traumatic stress disorder following traumatic childbirth, and suggests that this is under-diagnosed and represents a significant maternal morbidity which needs addressing, a suggestion also found by Ayers and Pickering (2001). Creedy et al (2000) state that “posttraumatic stress disorder after childbirth is a poorly recognized phenomenon,” and that “women who experienced both a high level of obstetric intervention and dissatisfaction with their intrapartum care were more likely to develop trauma symptoms than women who received a high level of obstetric intervention or women who perceived their care to be inadequate” (p 104).
Therefore, the focus on debriefing may not be the only way forward to improve psychological morbidity – there may be a need for research to explore ways of reducing the trauma that occurs in the first place. Czarnocka and Slade (2000) suggest that there may be opportunities for prevention of post traumatic stress and psychological morbidity after birth, through providing care in labour that enhances perceptions of control and support. One study demonstrates that negative experiences of interactions with maternity staff can contribute to psychological morbidity (Wijma et al, 1997).
Kenardy (2000) suggests that it is the nature of the debriefing that may be ineffective in those studies that have found such results. Gamble et al (2002) also suggest that the kind and timing of the debriefing warrants further investigation. Hagan et al (1996) did not find any reduction in psychological morbidity following this kind of intervention. Alexander (1999) suggests that some of the problems may be linked to the lack of clarity and understanding that exists about these processes, which are neither necessarily formal psychological counselling nor a simple sharing session.
Yet there does seem to be some indication that these kinds of supportive therapies are found to be useful by women and by midwives. Westley (1997) describes providing women with the opportunity to talk about their birth experiences, and have their questions answered, as useful, a finding supported by Smith et al (1996), Phillips (2003), Inglis (2002), Dennett (2003), Charles (1994), Charles and Curtis (1994), Baxter et al (2003), and Allott (1996). Certainly, a range of literature established post-traumatic stress disorder as a potential and/or real psychological morbidity for women having had a baby (Ayers and Pickering, 2001; Creedy et al, 2000; Laing, 2001; Menage, 1996; Robinson, 1999; Ballard et al, 1995; Crompton, 1996). Psychological debriefing interventions may be effective in preventing or managing post traumatic stress disorder in a range of situations (Rose et al, 2004), but there would seem to be some dangers inherent in some of the interventions found in the literature (Kenardy, 2000; Madden, 2002).
It would appear from the randomised controlled trials analysed here that while some evidence supports postnatal debriefing as a means of reducing psychological morbidity, significant evidence shows no correlation between postnatal interventions of this kind and improved emotional health outcomes. However, anecdotal evidence and other literature suggests that midwives and women find some benefit from opportunities to talk about their childbirth experiences. Some of these simply allow women an opportunity to talk and to ask questions about what happened to them. This leads to the conclusion that such interventions require much more research, preferably research which includes detailed, qualitative evaluations of interventions, and interventions which are specifically designed for this client group. However, this author would also recommend that such interventions be provided, as they are not proven to do harm in the majority of studies, and represent a woman-centred approach to good midwifery care.
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