Can midwives reduce postpartum psychological morbidity? A randomized trial. Evaluation of an interpersonal-psychotherapy-oriented childbirth education programme for Chinese first-time childbearing women: a randomised controlled trial. Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial. A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. Brief antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depression and anxiety: a randomised controlled trial. Stress debriefing after childbirth: a randomised controlled trial. Group counseling for mothers after emergency cesarean section: a randomized controlled trial of intervention. Advanced provision of emergency contraception to postnatal women in China makes no difference in abortion rates: a randomized controlled trial. Evaluation of antenatal and postnatal support to overcome postnatal depression: a randomized, controlled trial. IDentify, Educate and Alert (IDEA) trial: an intervention to reduce postnatal depression. A double-blind randomised placebo controlled trial of postnatal norethisterone enanthate: the effect on postnatal depression and serum hormones.
Women who are traumatized after childbirth find that listening, support, counseling, understanding, and explanation are the most useful treatments. However, little evidence is available from randomized trials of the relative efficacy of these treatments as a positive postnatal intervention. This study purpose was to examine if postnatal "debriefing" by midwives can reduce psychological morbidity after childbirth.
                A randomized trial was conducted in a regional teaching hospital in northwest England. One hundred and twenty postnatal primigravidas were allocated by sealed envelopes to receive the debriefing intervention (n = 56) or not (n = 58). The main outcome measure was the Hospital Anxiety and Depression (HAD) scale administered by postal questionnaire 3 weeks after delivery. The proportion of women in each group with anxiety and depression scores of more than 10 points were compared, using odds ratios and 95% confidence intervals.
                Women who received the intervention were less likely to have high anxiety and depression scores after delivery when compared with the control group.
                The support, counseling, understanding, and explanation given to women by midwives in the postnatal period provides benefits to psychological well-being. Maternity units have a responsibility to develop a service that offers all women the option of attending a session to discuss their labor. This study investigated the effects of an interpersonal-psychotherapy-oriented childbirth psychoeducation programme on postnatal depression, psychological well-being and satisfaction with interpersonal relationships in Chinese first-time childbearing women.
                A randomised, controlled trial was conducted in the maternity clinic of a regional hospital in China. The intervention was based on the principles of interpersonal psychotherapy, and consisted of two 90-min antenatal classes and a telephone follow-up within 2 weeks after delivery. One hundred and ninety-four first-time pregnant women were randomly assigned to the intervention group (n=96) or a control group (n=98). Outcomes of the study included symptoms of postnatal depression, psychological well-being and satisfaction with interpersonal relationships, which were measured by the Edinburgh Postnatal Depression Scale (EPDS), General Health Questionnaire (GHQ) and Satisfaction with Interpersonal Relationships Scale (SWIRS), respectively.
                Women receiving the childbirth psychoeducation programme had significantly better psychological well-being (t=-3.33, p=0.001), fewer depressive symptoms (t=-3.76, p=0.000) and better interpersonal relationships (t=3.25, p=0.001) at 6 weeks postpartum as compared with those who received only routine childbirth education.
                An interpersonal-psychotherapy-oriented childbirth psychoeducation programme could be implemented as routine childbirth education with ongoing evaluation. Replication of this study with more diverse study groups, such as mothers with high risks to depression, those with multiple, complicated or multiparas pregnancies, would provide further information about the effects of the programme.
                Copyright (c) 2010 Elsevier Ltd. All rights reserved. To evaluate the effectiveness of telephone based peer support in the prevention of postnatal depression.
                Multisite randomised controlled trial.
                Seven health regions across Ontario, Canada.
                701 women in the first two weeks postpartum identified as high risk for postnatal depression with the Edinburgh postnatal depression scale and randomised with an internet based randomisation service.
                Proactive individualised telephone based peer (mother to mother) support, initiated within 48-72 hours of randomisation, provided by a volunteer recruited from the community who had previously experienced and recovered from self reported postnatal depression and attended a four hour training session.
                Edinburgh postnatal depression scale, structured clinical interview-depression, state-trait anxiety inventory, UCLA loneliness scale, and use of health services.
                After web based screening of 21 470 women, 701 (72%) eligible mothers were recruited. A blinded research nurse followed up more than 85% by telephone, including 613 at 12 weeks and 600 at 24 weeks postpartum. At 12 weeks, 14% (40/297) of women in the intervention group and 25% (78/315) in the control group had an Edinburgh postnatal depression scale score >12 (chi(2)=12.5, P<0.001; number need to treat 8.8, 95% confidence interval 5.9 to 19.6; relative risk reduction 0.46, 95% confidence interval 0.24 to 0.62). There was a positive trend in favour of the intervention group for maternal anxiety but not loneliness or use of health services. For ethical reasons, participants identified with clinical depression at 12 weeks were referred for treatment, resulting in no differences between groups at 24 weeks. Of the 221 women in the intervention group who received and evaluated their experience of peer support, over 80% were satisfied and would recommend this support to a friend.
                Telephone based peer support can be effective in preventing postnatal depression among women at high risk.
                ISRCTN 68337727. To study the effectiveness of fluoxetine and cognitive-behavioural counselling in depressive illness in postnatal women: to compare fluoxetine and placebo, six sessions and one session of counselling, and combinations of drugs and counselling.
                Randomised, controlled treatment trial, double blind in relation to drug treatment, with four treatment cells: fluoxetine or placebo plus one or six sessions of counselling.
                87 women satisfying criteria for depressive illness 6-8 weeks after childbirth, 61 (70%) of whom completed 12 weeks of treatment.
                Community based study in south Manchester.
                Psychiatric morbidity after 1, 4, and 12 weeks, measured as mean scores and 95% confidence limits on the revised clinical interview schedule, the Edinburgh postnatal depression scale and the Hamilton depression scale.
                Highly significant improvement was seen in all four treatment groups. The improvement in subjects receiving fluoxetine was significantly greater than in those receiving placebo. The improvement after six sessions of counselling was significantly greater than after a single session. Interaction between counselling and fluoxetine was not statistically significant. These differences were evident after one week, and improvement in all groups was complete after four weeks.
                Both fluoxetine and cognitive-behavioural counselling given as a course of therapy are effective treatments for non-psychotic depression in postnatal women. After an initial session of counselling, additional benefit results from either fluoxetine or further counselling but there seems to be no advantage in receiving both. The choice of treatment may therefore be made by the women themselves. The majority of randomised controlled trials examining the effectiveness of antenatal group interventions at preventing postnatal depression in "at risk" women have used a "psychoeducational" intervention. The aim of the present study is to evaluate the effectiveness of an antenatal cognitive behavioural group intervention in a primary care setting for pregnant women identified with mild to moderate symptoms in pregnancy and/or at risk of developing depression or anxiety in the perinatal period.
                Subjects were randomised to a CBT group intervention or control condition (information booklet) and administered the EPDS and STAI at pre (Time 1) and post intervention (Time 2), and at 2 months (Time 3) and 4 months postpartum (Time 4). MINIs were administered at Times 1, 3 and 4.
                Of the 774 women approached, 277 accepted and were suitable; thus 191 were randomised to the CBT intervention and 86 to the control condition. The subsequent 52% drop-out left 89 women "completing" the CBT groups and 43 in the control group; these two groups were well matched on demographic variables. Intention to treat analyses revealed relatively low mean baseline EPDS scores (means 6.88 -8.16) with no reduction in EPDS scores in either group from Time 1 to Time 4. MINI depression criteria were fulfilled by 19% of all participants at Time 1 but there was no reduction in depression in either group; in contrast those with MINI anxiety diagnoses reduced from 28% in late pregnancy to 16% at four months postpartum in the CBT group with similar reductions in the control group. Analyses on the 132 "completers" showed significant symptomatic improvement over time for both the CBT group and control condition. Depression scores in the most symptomatic women (EPDS>12; N=19) decreased steadily by over 50% over the total time course but there were no differences in improvement between the CBT and control groups.
                A number of methodological factors may have obscured our results including a tendency to natural remission in mildly symptomatic subjects and the possibility that our control condition was therapeutic in itself.
                While a modest reduction in depression scores was noted in study "completers", both the CBT group intervention control condition were equally beneficial. The reasons for this finding include the low symptom level at baseline; the potential effectiveness of the control condition; and the brevity of the intervention. To test whether critical incident stress debriefing after childbirth reduces the incidence of postnatal psychological disorders.
                Randomised single-blind controlled trial stratified for parity and delivery mode.
                Two large maternity hospitals in Perth.
                1745 women who delivered healthy term infants between April 1996 and December 1997 (875 allocated to intervention and 870 to control group).
                An individual, standardised debriefing session based on the principles of critical incident stress debriefing carried out within 72 hours of delivery.
                Diagnosis of stress disorders or depression in the 12 months postpartum, using structured psychological interview and criteria of the Diagnostic and statistical manual of mental disorders, 4th edition.
                Follow-up information was available for 1730 women (99.1%), 482 of whom underwent psychological interview. 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).
                There is a high prevalence of depression in women during the first year after childbirth. A session of midwife-led, critical incident stress debriefing was not effective in preventing postnatal psychological disorders, but had no adverse effects. 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.
                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).
                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.
                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. Emergency contraception (EC) prevents pregnancy, and it has been suggested that widespread use could reduce abortion rates; however, the use is limited. Providing EC in advance of need increases use, but there is no direct evidence that it reduces unintended pregnancy. In a randomized controlled trial of 2000 women after childbirth in Shanghai, all women not wishing to use hormonal contraception or an intrauterine device (IUD) were given a supply of condoms. Those in the intervention group also received three courses of mifepristone 10 mg with instructions for use as EC. Follow-up was by telephone at 16, 32 and 52 weeks. Over 88% of women in both groups completed 1 year of follow-up. Women with a supply of EC were more than twice as likely to use it, and to use it more than once (p<.001 for both) than women without a supply. There was no difference in pregnancy rates at 1 year (38/832 vs. 32/817). EC was not used in 89% of conception cycles, as women did not recognize the need for it. Increased use of EC may not reduce abortion rates. This randomized, controlled trial tested the hypothesis that women identified as more vulnerable to developing postnatal depression who attended two specific antenatal groups and one postnatal group have a reduced frequency of postnatal depression from 37 to 15 percent at 6 weeks, 12 weeks, and 6 months postpartum. A modified antenatal screening questionnaire was completed, and women identified as more vulnerable to postnatal depression were stratified by parity and randomly allocated to receive extra support groups or to a control group. The Edinburgh Postnatal Depression Scale (EPDS) was used to detect postnatal depression. Attendance at the support groups was low, 31 percent overall. At six weeks, in the intervention group, 8 (13%) of 64 women scored high (> 12) on the EPDS, compared with 11 (17%) controls. Similarly, at 12 weeks 7 (11%) of 63 versus 10 (15%) of 65 women scored higher than 12, and at 6 months, 9 (15%) of 60 versus 6 (10%) of 64 women scored higher than 12, indicating that the intervention did not reduce postnatal depression. It is possible that the method of applying the intervention, using groups separate from the standard antenatal classes, may have affected attendance. More research is required into ways of reaching and supporting women who may become depressed. To test the effectiveness of a prenatal intervention in reducing the incidence of postnatal depression.
                A randomized controlled trial.
                A large metropolitan obstetric hospital.
                Pregnant women with risk factors for postnatal depression.
                Women attending their first prenatal visit at the Royal Women's Hospital, Brisbane, were screened for risk factors for postnatal depression (IDentify). Positively screened women were randomly allocated to the intervention group or the control group. The intervention consisted of a booklet about postnatal depression, which included contact numbers; prenatal screening using the Edinburgh Postnatal Depression Scale; a discussion with the woman about her risk of developing postnatal depression (Educate); and a letter to the woman's referring general practitioner and local Child Health Nurse, alerting them of the woman's risk for postnatal depression (Alert).
                Edinburgh Postnatal Depression Scale Score > 12 at 16 weeks postpartum.
                Of the 509 women who were sent a follow-up questionnaire, 371 (72.9%) responded. The proportion of women who reported an Edinburgh Postnatal Depression Scale score of >12 was 26%. There were no significant differences between intervention (46/192, 24%) and control groups (50/177, 28.2%) on this primary outcome measure (OR 0.80; 95% CI 0.50-1.28).
                Over one-quarter of women with risk factors will develop postnatal depression. It is a treatable disorder but under-diagnosis is common. Efforts to reduce postnatal depression by implementing interventions in the prenatal period have been unsuccessful. To determine the effect of postnatal administration of the long-acting progestogen contraceptive, norethisterone enanthate, on postnatal depression and on serum hormone concentrations, and their association with depression.
                Double-blind randomised placebo-controlled trial.
                A tertiary care hospital in Johannesburg, South Africa. POPULATION Postnatal women using a non-hormonal method of contraception (n = 180).
                Random allocation within 48 hours of delivery to norethisterone enanthate by injection, or placebo.
                Depression scores in the three months postpartum as rated by the Montgomery-Asberg Depression Rating Scale (MADRS) and the Edinburgh Postnatal Depression Scale (EPDS); 2. serum 17beta-oestradiol, progesterone, testosterone and the 17beta-oestradiol:progesterone ratio at six weeks postpartum.
                There was a chance excess of caesarean section deliveries in the progestogen group. Mean depression scores were significantly higher in the progestogen group than in the placebo group at six weeks postpartum (mean MADRS score 8.3 vs 4.9; P = 0.0111; mean EPDS score 10.6 vs 7.5; P = 0.0022). Mean serum 17beta-oestradiol and progesterone concentrations were significantly lower in the progestogen group compared with the placebo group at six weeks postpartum. There were no correlations between any of the hormone parameters and depression at six weeks except in the formula feeding subgroup of the placebo group, where formula feeding and 17beta-oestradiol concentrations were positively associated with depression.
                Long-acting norethisterone enanthate given within 48 hours of delivery is associated with an increased risk of developing postnatal depression and causes suppression of endogenous ovarian hormone secretion.
There was no evidence available from randomised controlled trials to assess the effectiveness of hypnosis during pregnancy, childbirth, and the postnatal period for preventing postnatal depression. Evidence from randomised controlled trials is needed to evaluate the use and effects of hypnosis during the perinatal period to prevent postnatal depression. Two trials are currently underway which may provide further information in the future.