Preventing Post-Traumatic Stress Disorder following Childbirth: A Systematic Review and Meta-Analysis

Abstract

Objective:

Women can develop post-traumatic stress disorder (PTSD) in response to experienced or perceived traumatic, often medically complicated, childbirth; U.S. prevalence of these events remains high. Currently, no recommended treatment exists in routine care for preventing or mitigating maternal childbirth-related PTSD (CB-PTSD). We provide a systematic review and meta-analysis of clinical trials testing any therapy to prevent or treat CB-PTSD.

Data Sources:

PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for eligible trials published through September 2023.

Study Eligibility Criteria:

Trials were included if they were interventional, evaluated any therapy for CB-PTSD, for indication of symptoms or before PTSD onset, and written in English.

Study Appraisal and Synthesis Methods:

Independent coders extracted sample characteristics and intervention information of eligible studies and evaluated trials using Downs and Black’s quality checklist and Cochrane’s method for risk of bias. Meta-analysis was conducted to evaluate pooled effect sizes of secondary and tertiary prevention trials.

Results:

41 studies (32 randomized controlled trials, 9 non-randomized trials) were reviewed. They tested brief psychological therapies entailing debriefing, trauma-focused (including cognitive behavioral therapy and expressive writing), memory consolidation/reconsolidation blockage, mother-infant-focused, and educational interventions. Trials targeted secondary prevention to buffer CB-PTSD usually after traumatic childbirth (n=24), tertiary preventions in women with probable CB-PTSD (n=14), and primary prevention during pregnancy (n=3).

Meta-analysis of combined randomized secondary preventions showed moderate effects for reducing CB-PTSD symptoms against treatment as usual (standardized mean difference, SMD =−0.67; 95% CI −0.92, −0.42). Single-session therapy within 96 hours postpartum was helpful (SMD=−0.55). Brief structured trauma-focused therapies and semi-structured midwife-led dialogue-based psychological counseling showed the largest effects (SMD=−0.95 and SMD=−0.91, respectively). Other treatment approaches (e.g., Tetris game, mindfulness, mother-infant-focused) warrant more research. Tertiary preventions represented smaller effects vs. secondary, but are potentially clinically meaningful (SMD = −0.37 (−0.60; −0.14)). Antepartum educational approaches may help, but insufficient empirical evidence exists.

Conclusions:

Brief trauma-focused and non-trauma-focused psychological therapies delivered in the early period following traumatic childbirth offer a critical and feasible opportunity to buffer symptoms of childbirth-related PTSD. Future research integrating diagnostics and biological measures can inform treatment utility and the mechanisms at work.

Introduction

Childbirth is a profound experience often entailing extreme physical and psychological stress. Among delivering women, an estimated 1/3 experience highly stressful and potentially traumatic childbirth,^1–3 and ~60,000 women in the U.S. each year experience severe maternal morbidity (SMM).⁴ SMM rates in the U.S. are among the highest in Western countries^5–7 and steadily continue to increase.^5,8–10

Complicated deliveries may undermine maternal psychological welfare. Post-traumatic stress disorder (PTSD) is the formal psychiatric disorder resulting from exposure to death or threatened death or serious injury, experienced or witnessed.¹¹ Existing research provides validation for PTSD stemming from a traumatic childbirth experience.¹² This includes events that threaten the woman’s life or cause her to believe that her life, or her infant’s life, is in danger. A broader definition of birth trauma pertains to interactions and/or events directly related to childbirth that cause overwhelming distressing emotions and reactions, and can have negative impact on women’s well-being.¹³

Childbirth-related PTSD (CB-PTSD) is estimated to affect 5–6% of all postpartum women;^3,14,15 this translates to 240,000 affected American women each year. 18.5% to 41.2% of women^15–17 will develop CB-PTSD following complicated delivery. Black and Latinx women are nearly three times more likely to endorse childbirth-related traumatic stress.¹⁸

Although highly co-morbid with peripartum depression,^19–22 CB-PTSD is a distinct condition largely consistent with the formal symptom constellation of PTSD.²³ This includes trauma (childbirth)-related intrusion symptoms such as flashbacks and nightmares; attempts to avoid reminders of childbirth; negative alterations in cognitions and mood; and marked arousal and reactivity manifested primarily in irritability, sleep and concentration problems, and hypervigilance.^24–26

When left untreated, CB-PTSD can impair maternal functioning during the important postpartum period and pose risks for the child’s health. Women with CB-PTSD may exhibit reduced breastfeeding and impairment in affectional and behavioral maternal-infant bonding,^27–30 which is instrumental for healthy child socio-emotional development.^29,31 CB-PTSD may result in infant behavioral and temperamental problems.³¹ It can further lead to avoidance of physical intimacy and disincentivize future pregnancies.^32–34 These features suggest that CB-PTSD is a distinct sub-type of PTSD.^12,35

CB-PTSD has unique attributes that support the potential for early intervention and even prevention. The symptoms ensue after a specified time-defined event (childbirth),^20,22,36,37 indicative of a clear onset, and usually during maternity hospitalization stay. Hence, there is access to exposed individuals, unlike after most other traumas. The biological underpinnings and proposed pathophysiology of PTSD suggest that in the period after exposure to a traumatic event and before the full manifestation of the disorder, there is a window in which biological and psychological processes can be promoted that can prevent or reduce over-consolidation of the traumatic memory.^19,38–41 Consequently, early interventions delivered before the development of the full traumatic stress syndrome may prevent PTSD.^38–41

Presently, there is critical gap in knowledge to inform clinical recommendations for treatment of choice for CB-PTSD. Early systematic reviews used the limited number of available trials, preventing conclusions about the utility of psychological debriefing and counseling.^42–44 More recent systematic reviews,^45–50 including 3 meta-analyses, covering publication through March 2020, concluded that trauma-focused interventions delivered after childbirth appear helpful for alleviating symptoms of CB-PTSD (see Supplementary Table 1: List of Acronyms and Abbreviations) in the short term, but that more studies were warranted to establish recommendations.

Objectives

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and non-randomized trials to inform which therapies are most promising for CB-PTSD, what the optimal timing for intervention may be, and which populations will benefit most from the interventions. We reviewed all 3 types of preventive interventions including primary, secondary, and tertiary prevention approaches (see Supplementary Table 2: Glossary of Terms). We evaluated the quality of all trials combining commonly used methods pertaining to quantitative⁵¹ and risk of bias^52,53 assessments. To the best of our knowledge, this approach has never been implemented before.

Methods

a. Eligibility Criteria, Information Sources and Search Strategy

Studies were independently evaluated according to the PICOS framework (Supplementary Table 3) and met the following criteria: a) interventional; b) indication of any type of treatment for PTSD specified as stemming from childbirth or its implications; c) indication of post-treatment measurement of CB-PTSD, and d) written in the English language. Duplicate studies, case reports, study protocols, active clinical trials, and trials without results of CB-PTSD outcome or entailing cases of stillbirth were excluded.

The review was conducted according to PRISMA guidelines;⁵⁴ the study protocol was registered on PROSPERO (CRD42020207086). We searched PsycInfo, PsycArticles, PubMed, ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) for articles published through September 2023. Published reviews on CB-PTSD therapies served as additional resources. (See Supplementary Table 4 for search terms and criteria.)

b. Study Selection

A total of 41 clinical trials met inclusion criteria and were selected in accordance with the PRISMA workflow process (Figure 1).⁵⁴

Figure 1. PRISMA flow diagram for CB-PTSD intervention articles selection.

PRISMA flow diagram detailing the source selection process of both randomized and non-randomized clinical studies targeting childbirth-related post-traumatic stress disorder (CB-PTSD) in at-risk and universal samples.

c. Data Extraction

Three authors (J.P., R.N., and C.P.) independently extracted articles, and the pooled articles were discussed to achieve consensus. Important study information for each trial was extracted by one author and cross-checked by a second author and a Research Fellow (B.Q.) to ensure accuracy (Table 1). Information included sample characteristics, study design (randomized vs. non), sample type (universal or targeted), intervention type (primary/secondary/tertiary prevention), treatment modality and frequency/duration, primary and secondary outcome measurements, and post-treatment time point.

Table 1.

Description of clinical trials for childbirth-related PTSD prevention.

First Author (Year)	Country	Study Design	Sample Size	Sample Characteristics	Sample Type	Preventative Type	Treatment Modality	Intervention	Outcome Time Points	Outcome Measures	Results	Quality Score
Debriefing
Priest (2003)69	AUS	RCT	N=174	Not specified	Universal	2°	Debriefing, CIS	1 session (30–60 min) within 72hr PP Control: TAU	T1: 2mo PP T2: 6mo PP T3: 12mo PP	CB-PTSD (IES); PPD (EPDS); Psychological Interview (SADS*)	No Tx effect on CB-PTSD or PPD symptoms. Tx received as helpful.	Good (28)
Selkirk (2006)68	AUS	RCT	N=149	Not specified	Universal	2°	Debriefing	1 session (15–60 min) within 72h PP Control: TAU	T1: ≤48hrs PP T2: 1mo PP T3: 3mo PP	CB-PTSD (IES); PPD (EPDS); Anxiety (STAI); Parenting stress (PSI); Perception of the birth (POBS); Dyadic satisfaction (DAS); Feedback of debriefing (FAD)	Tx associated with negative childbirth perceptions in complicated deliveries; associated with better dyadic satisfaction. No Tx effect on PPD, anxiety, or parenting distress. Tx received as acceptable.	Fair (19)
Abdollahpour (B) (2019)70	IRN	RCT	N=193	Age, M = 26 yrs	Targeted: traumatic childbirth experience	2°	Debriefing or CBC	1 debriefing or CBC session (40–60 min) within 48hrs PP Control: TAU	T1: 4–6wks PP T2: 3mo PP	CB-PTSD (IES-R)	Positive debriefing Tx effect on CB-PTSD symptoms at T1 and T2, compared to TAU. Debriefing Tx inferior to CBC Tx at T1 and T2.	Good (22)
Kershaw (2005)71	GBR	RCT	N=319	85% White 91% Partnered Majority employed	Targeted: first childbirth via operative delivery	2°	Debriefing, CIS	2 sessions (≤90 min each) at 10 days and 10wks PP Control: TAU	T1: 10days PP T2: 10wks PP T3: 20wks PP	CB-PTSD (IES); FoC (WDEQ)	No Tx effect on CB-PTSD symptoms or FoC.	Good (26)
Meades (2011)72	GBR	NRCT	N=80	Age, M = 34 yrs	Targeted: DSM-IV criterion A	3°	Debriefing	1 session (60–90 min) within Mdn=16 wks PP Control: TAU	T1: 1mo post-Intervention	CB-PTSD (PSS-SR); PPD (EPDS); Negative appraisal (PTCI)	Positive Tx effect on CB-PTSD and negative childbirth appraisals. No Tx effect on PPD.	Fair (17)
Crisis Intervention
Jotzo (2005)74	DEU	NRCT	N=50	Age, M = 31yrs 98% Partnered	Targeted: preterm infant in NICU	2°	Trauma-preventative Crisis Intervention Program	1 session within 5 days PP with availabilities of psychological support Control: TAU with availability of hospital minister counseling	T1: Post-intervention	CB-PTSD (IES); Peritraumatic dissociative experiences (PDEQ)	Positive Tx effect on CB-PTSD symptoms; intrusion, avoidance, and hyperarousal.	Fair (19)
Trauma-Focused Cognitive Behavioral Therapy
Abdollahpour (A) (2019)70	IRN	RCT	N=193	Age, M = 26yrs	Targeted: traumatic childbirth experience	2°	CBC or Debriefing	1 debriefing or CBC session (40–60 min) within 48hrs PP Control: TAU	T1: 4–6wks PP T2: 3mo PP	CB-PTSD (IES-R)	Positive CBC Tx effect on CB-PTSD symptoms at T1 and T2, compared to TAU. Debriefing Tx inferior to CBC Tx at T1 and T2.	Good (22)
Shaw (2013,2014)76,77	USA	RCT	N=105	Age, M = 32yrs 61% White 96% Partnered 53% Income ≥$100K	Targeted: preterm infant in NICU; acute stress (SASRQ ≥3), PPD (BDI-II ≥20), and anxiety (BAI ≥16) symptoms	2°	TF-CBT	6 sessions (~50 min) within 1–2wks PP Control: TAU with 1 educational session. 6-mo follow-up to Shaw 2013, with the option of three additional CBT sessions (total 9 sessions)	T1: 1wk post-intervention T2: 4–5wks PP T3: 6mo PP	CB-PTSD (TES; DTS); Traumatic events (PSS:NICU; MINI-I*); Anxiety (BAI); PPD (BDI-II)	Positive Tx effect on CB-PTSD and PPD symptoms at T1 and T2; at T3 only for women who received additional sessions. No Tx effect on anxiety.	Good (27)
Bernard (2011)78	USA	RCT	N=56	Age, M= 33yrs 46% Partnered Length of Education, M=16yrs	Targeted: preterm infant in NICU	2°	TF-CBT	3 sessions (~50 min) over 2wks while infant was in NICU (exact time of intervention delivery not specified). Control: TAU	T1: 1mo post-NICU discharge	CB-PTSD (DTS); PPD (BDI); Intervention Feedback	No Tx effect after adjusting for CB-PTSD at baseline. Trend in positive Tx effect on PPD symptoms. Tx received as beneficial.	Fair (21)
Simon (2021)79	USA	NRCT	N=19	32% White 100% Partnered 89% Employed 68% ≥Bachelor’s degree	Targeted: preterm infant in NICU	2°	Trauma-focused group intervention	6 sessions (90 min) over 3wks following preterm birth (exact PP timeframe not specified) Control: None	T1: 6wks post-intervention T2: 6mo PP	CB-PTSD (DTS); Anxiety (BAI); PPD (BDI-II); Maternal Satisfaction Questionnaire; Intervention Feedback	Positive Tx effect on PPD symptoms at T1; on CB-PTSD and anxiety symptoms at T2. Tx received as highly satisfactory and helpful.	Fair (20)
Nieminen (2016)80	SWE	RCT	N=56	Age, M = 35yrs 95% Partnered 68% Employed 80% ≥University degree	Targeted: CB-PTSD symptoms (TES ≥30)	3°	TF-iCBT	8 sessions over 8wks within ~2.8 years PP Delayed control: Tx 5mo later	T1: 8wks post-intervention T2: Post-intervention for delayed Tx group (control)	CB-PTSD (MINI-I*; TES; IES-R); PPD (BDI-II; PHQ-9); Anxiety (BAI); Quality of Life (QOLI; EQ5D)	Positive Tx effect on CB-PTSD, PPD, and anxiety symptoms in Tx and delayed Tx groups. Positive Tx effect on quality of life in Tx group at T1.	Good (26)
Sjömark (2022)81	SWE	RCT	N=266	Age, M = 32yrs 98% Partnered 73% University degree	Targeted: Self-reported negative childbirth experience and/or unplanned Cesarean-section and/or severe hemorrhage	3°	TF-iCBT	Part I: 6-wk online-based protocol ~2–4mo PP Part II: structured weekly therapeutic support, email-based program given over 8 wks after Part I Control: TAU	T1: 6wks post-intervention T2: 14wks post-intervention T3: 1yr post-intervention	CB-PTSD (TES); PPD (EPDS)	No Tx effect on CB-PTSD or PPD symptoms.	Good (23)
EMDR
Chiorino (2020)84	ITA	RCT	N=37	Age, M = 34yrs 86% Italian 97% Partnered 62% Employed 60% ≥ University degree	Targeted: CB-PTSD symptoms (IES-R ≥24)	2°	EMDR	1 session (90 min) within 3 days PP Control: TAU with a single session of psychological supportive therapy	T1: 6wks PP T2: 3mo PP	CB-PTSD (IES-R; PDEQ); PPD (EPDS); Mother-Infant-Bonding (MIBS)	Positive Tx effect on CB-PTSD symptoms, flashbacks, and distress at T1 and T2. No Tx effects on PPD or mother-infant-bonding.	Good (25)
Kopmeiners (2023)85	NLD	RCT	N=20	Age, M=34yrs 54.5% Higher Education	Targeted: DSM-5 clusters B, C, and E (>2 on at least 1 criterion)	3°	EMDR	1–3 Sessions (1–2 hrs) delivered between 6–12 wks PP Control: TAU	T1: 3mo PP T2: 6mo PP T3: 12mo PP	CB-PTSD (PPQ, PCL-5); Distress, depression, anxiety and somatization (4DSQ); 30-min semi-structured interviews *	Trend in positive Tx effect on CB-PTSD symptoms at T1. No Tx effect on distress, PPD, anxiety, and somatization. From interview, improved childbirth perceptions and physical/mental complaints.	Good (26)
Sandström (2008)62	SWE	Pilot NRCT	N=4	Age, M = 28yrs 100% Partnered	Targeted: CB-PTSD diagnosed	3°	EMDR	Multiple sessions in women with previous traumatic births Control: None	T1: Post-intervention T2: 1–3yrs post-intervention	CB-PTSD (TES); Data from interviews and psychotherapist notes *	Tx on CB-PTSD symptoms at T1 and T2 appears helpful.	Poor (13)
Kranenburg (2022)86	NLD	NRCT	N=26	Age, M=32	Targeted: CB-PTSD diagnosed, or severe symptoms and another DSM-5 diagnosis	3°	EMDR	Up to 8 (M=5) weekly sessions delivered ≥4wks PP (M=10mo) Control: None	T1: Post-intervention, time not specified	CB-PTSD (PCL-5, LEC-5)	Positive Tx effect on CB-PTSD symptoms. All patients previously meeting CB-PTSD diagnosis criteria lost diagnoses post-intervention.	Fair (19)
Expressive Writing
Di Blasio (2002)90	ITA	RCT	N=64	Age, M = 33yrs 33% ≥ High School	Universal	2°	EW	1 session (10–15 min) 2 days PP writing about thoughts/feelings of delivery experience Control: TAU, no writing task	T1: 48hrs PP T2: 2mo PP	CB-PTSD (PPQ)	Positive Tx effect on CB-PTSD symptoms; hyperarousal and avoidance at T1. Positive Tx effect on re-experiencing and avoidance at T2.	Fair (21)
Di Blasio (2009)91	ITA	RCT	N=242	Age, M = 32yrs 100% Partnered 89% ≥ high school	Universal	2°	EW	1 session (10–15 min) 2 days PP writing about thoughts/feelings of delivery experience Control: TAU, no writing task	T1: 48hrs PP T2: 2mo PP T3: 12mo PP	CB-PTSD (PPQ)	Positive Tx effect on CB-PTSD symptoms at T1 and T2; hyperarousal at T1, T2, and T3; avoidance at T1.	Good (22)
Di Blasio (2015)92	ITA	RCT	N=176	Age, M = 32yrs 84% Partnered 78% Employed 85% ≥ High School	Universal	2°	EW	1 session (20 min) within 96hrs PP writing about thoughts/feelings of delivery experience Control: writing about daily events	T1: 96hrs PP T2: 3mo PP	CB-PTSD (LASC; PPQ); PPD (BDI-II)	Positive Tx effect on CB-PTSD symptoms at T2. Positive Tx effect on PPD symptoms at T1 and T2.	Good (23)
Di Blasio (2015)93	ITA	RCT	N=113	Age, M = 31 yrs, 80% Partnered, 80% Employed, 86% ≥ High School	Universal	2°	EW	2 sessions (15–20 min each) within 96hrs PP writing about thoughts/feelings of delivery experience Control: writing about daily events	T1: 3mo PP	CB-PTSD (PPQ); PPD (BDI-II); Essay Content	Positive Tx effect on CB-PTSD and PPD symptoms, especially for women with moderate-to-severe PTS symptoms.	Fair (20)
Horsch (2016)94	CHE	RCT	N=67	Age, M = 31yrs 56% Partnered	Targeted: preterm infant in NICU	3°	EW	3 writing tasks (15 min each) over 3 consecutive days at 3mo PP Control: TAU	T1: 4mo PP T2: 6mo PP	CB-PTSD (PPQ); PPD (EPDS); Mental and physical health status (SF-36); Intervention Satisfaction (5-point Likert Scale)	Positive Tx effect on CB-PTSD and PPD symptoms at T1 and T2. Positive Tx effect on mental health status at T2. Tx received as satisfactory.	Good (27)
Barry (2001)95	USA	RCT	N=38	Age, M = 33yrs 89% Partnered	Targeted: infant in NICU	3°	EW	4 writing tasks (30 min each) over 4 consecutive days within 2–14 mo of infant NICU hospitalization Control: Waiting-list	T1: 1mo Post-intervention	CB-PTSD (SCL-90-R; IES-R)	Positive Tx effect on CB-PTSD symptoms.	Fair (21)
Memory Consolidation/Reconsolidation Blockage
Horsch (2017)98	CHE	RCT	N=56	Age, M = 33yrs 91% White 88% Partnered 64% ≥ Bachelor’s degree	Targeted: ECS	2°	Visuospatial Cognitive Task	1 Tetris session (15 min) within 6hrs of ECS Control: TAU	T1: 1wk PP T2: 1mo PP	CB-PTSD (PDS); Anxiety and PPD (HADS); Acute distress (ASDS); Diary accounts of intrusive memories	No Tx effect on CB-PTSD, PPD, anxiety, or distress. Positive Tx effect on acute stress symptoms and intrusive memories at T1.	Good (26)
Deforges (2023)99	CHE	RCT	N=146	Age, M=33.9yrs	Targeted: UCS and traumatic childbirth experience	2°	Visuospatial Cognitive Task	1 Tetris session (15 min) within 6hrs of UCS Control: Written activity log	T1: 6wk PP T2: 6mo PP	CB-PTSD (CAPS-5*; PCL-5); Diary report of intrusive memories	Trend in positive Tx effect in self-reported CB-PTSD symptoms at T1 and T2. Positive Tx effect on arousal, cognition and mood at T2. No Tx effect on clinician-assessed (CAPS-5) CB-PTSD symptoms.	Good (28)
Deforges (2022)100	CHE	NRCT	N=18	Age, M=33 94% Partnered 56% University degree	Targeted: CB-PTSD intrusive symptoms	3°	Visuospatial Cognitive Task	1 Tetris session (20 min) delivered at M=2 years PP Control: None	T1: 1–2wks post-intervention T2: 5–6wks post-intervention	CB-PTSD (PCL-5); Diary report of intrusive memories	Positive Tx effect on CB-PTSD symptoms at T2. Positive Tx effect on intrusive memories at T1 and T2. All women (n=8) previously diagnosed with CB-PTSD lost diagnoses post-intervention.	Good (23)
Psychological Counseling
Asadzadeh (2020)103	IRN	RCT	N=90	Age, M = 25yrs 40% University degree	Targeted: DSM-5 criterion A met	2°	Counseling	1 session (40–60 min) within 72hrs of delivery, 1 telephone session at 4–6wks PP Control: TAU	T1: 4–6wks PP T2: 3mo PP	CB-PTSD Checklist (PCL-5); PPD (EPDS); Anxiety (HAM-A*)	Positive Tx effect on CB-PTSD, PPD, and anxiety symptoms at T1 and T2.	Good (24)
Bahari (2022)104	IRN	RCT	N=166	Age, M = 27yrs 11% Employed 63% ≥ high school	Targeted: ECS or vaginal delivery and DSM-5	2°	Counseling	1 in-person session (45–60 min) at 48hrs PP, 1 session (45–90 min) at 15 days PP, and 1 telephone session (15–20 min) at 4–6wks PP Control: TAU	T1: 2mo PP	CB-PTSD (PCL-5); PPD (EPDS); Mother-Infant Bonding (PBQ)	Positive Tx effect on CB-PTSD and PPD symptoms, and mother-infant bonding.	Good (26)
Gamble (2005)105	AUS	RCT	N=103	Age, M = 28yrs 93% White 85% Partnered 60% ≥ High school	criterion A Targeted: DSM-IV criterion A	2°	Counseling	1 in-person session (40–60 min) within 72hrs of delivery, 1 telephone session at 4–6wks PP Control: TAU	T1: 4–6wks PP T2: 3mo PP	CB-PTSD (MINI-I*); PPD (EPDS; DASS-21); Anxiety/Stress (DASS-21); Self-blame and confidence about a future pregnancy (MSSS); Intervention Feedback	Positive Tx effect on CB-PTSD and PPD symptoms; feelings of self-blame and confidence about a future pregnancy. No Tx effect on CB-PTSD diagnoses, anxiety, or stress symptoms. Tx received as useful.	Good (23)
Ryding (1998)106	SWE	RCT	N=99	Age, M = 30 yrs	Targeted: ECS	2°	Counseling	3 or 4 sessions (each 45–60 min) delivered during the first days to 3wks PP Control: TAU	T1: 1mo PP T2: 6mo PP	CB-PTSD (IES); Cognitive appraisal of delivery and distress (W-DEQ; SCL)	Positive Tx effect on CB-PTSD symptoms and cognitive appraisal of delivery and distress at T1 and T2. No positive Tx effect on women with the most serious stress reactions.	Fair (18)
Ryding (2004)107	SWE	RCT	N=162	Age, M = 32 yrs	Targeted: ECS	3°	Group Counseling	2 group sessions (1 hr each) at 1–2mo PP Control: TAU	T1: 6mo PP	CB-PTSD (IES); PPD (EPDS); FoC (WDEQ)	No positive Tx effect on CB-PTSD, PPD, or FoC symptoms.	Good (23)
Mother-Infant Focused Interventions
Abdollahpour (2016)109	IRN	RCT	N=84	Age, M = 26 yrs	Targeted: DSM-5 criterion A	2°	Skin-to-skin Contact	SSC according with 9-instinctive stage magical hour protocol in the immediate post-birth period Control: TAU	T1: 2wks PP T2: 4–6wks PP T3: 3mo PP	CB-PTSD (IES-R)	Positive Tx effect on CB-PTSD symptoms at T1 and T3.	Good (23)
Borghini (2014)111	CHE	RCT	N=26	Age, M = 32 yrs	Targeted: preterm infant in NICU	3°	Mother-Infant Attachment	Infant observation at 33wks PP, clinical interview at 42wks PP, 3 sessions at 4mo PP, 1wk apart, of mother-infant free play Control: (1) TAU in mothers of preterm infants without intervention, and (2) of mothers with term infants	T1: 42wks PP T2: 4mo PP T3: 12mo PP	PTS (PPQ); Mother-child interactions (NBAS)	Positive Tx effect on CB-PTSD at T1, T2, and T3. Positive Tx effect on maternal sensitivity and infant cooperation at T2 in the preterm group.	Good (26)
Holditch-Davis (2014)110	USA	RCT	N=240	Age, M=27 32% Partnered Years education, M= 13.4yrs	Targeted: preterm infant in NICU	2°	Auditory-tactile-visual-vestibular (ATVV) intervention or kangaroo care (KC)	Two intervention groups – ATVV (15 min) or KC (15 min) – performed at least 3 sessions/wk beginning in the NICU until 2mo corrected age with their infant. Control: Attention control group received educational visits with a study nurse weekly to discuss taking care of a preterm infant.	T1: 2mo CA T2: 6mo CA T3: 12mo CA	CB-PTSD (PPQ); Depression (CESD); Anxiety (STAI); Stress (PSS); Mother-child interactions (NBAS); Home Environment (HOME)	No positive Tx effect on CB-PTSD, PDD, or anxiety symptoms. No Tx effect on mother-child interactions. Positive Tx effect on parenting stress and HOME scores for both Tx groups compared to TAU.	Good (25)
Zelkowitz (2011)112	CAN	RCT	N=121	Age, M = 31yrs 88% Partnered 6% Employed 66% ≥ Junior college; Income, M = $59K	Targeted: infant of very low birth weight in NICU	3°	Mother-Infant Attachment (Cues group)	6 sessions on teaching mothers to cope and interact with their children ~33d ±12d PP to 6–8wks PP Control: TAU, standard infant care resources	T1: Immediate post-intervention timeframe	CB-PTSD (PPQ); PPD (EPDS); Anxiety (STAI); Stress (PSI); Intervention Feedback	No positive Tx effect on CB-PTSD, PPD, or anxiety symptoms. No Tx effect on parenting stress. Tx received as satisfactory.	Good (23)
Alternative Psychological Interventions
Schlesinger (2022)115	ISR	NRCT	N=95	Age, M = 29yrs 91% Partnered 79% Employed	Universal	1°	Visual Biofeedback	1 session (~5 min) during labor. Control: TAU, standard labor	T1: 2d PP T2: 1mo PP	CB-PTSD (PCL-S); Acute Stress (SASRQ); FoC (PTS-FC); Maternal attachment self-report Likert-type scale	Positive Tx effect on CB-PTSD symptoms via increased feelings of maternal connectedness, which was associated with reduced acute stress levels at T1. Indirect Tx effect on CB-PTSD symptoms at T2.	Fair (18)
Izadi (2022)117	IRN	RCT	N=60	Age, M=30yrs 33.33% >Associates degree; 10% employed	Targeted: preterm infant in NICU	2°	Mindfulness	2 weekly MBSR-sessions (each ~90 min) for 3wks. Control: TAU/delayed control if women wished to receive intervention later	T1: Post-intervention T2: 1mo post-intervention	CB-PTSD (IES-R)	Positive Tx effect on CB-PTSD symptoms at T1 and T2.	Good (24)
Kobus (2023)120	DEU	RCT	N=33	Age, M=32yrs 19.2% White 27% Higher education	Targeted: preterm infant in NICU	2°	Music therapy	2 weekly sessions of music therapy until discharge. Control: TAU	T1: 1wk PP T2: Infant’s discharge	CB-PTSD (IES-R); Depression (CES-D)	Positive Tx effect on CB-PTSD symptoms at T1, especially for hyperarousal. Positive Tx effect on PPD symptoms at T2.	Fair (21)
Pourmovahed (2021)121	IRN	RCT	N=45	Age, M=28yrs 27% Bachelor’s or higher	Targeted: preterm infant in NICU	3°	Music therapy	Daily sessions (20–30 min) listening to non-verbal music with infant for 2wks during NICU stay (exact timing of intervention onset not specified). Control: TAU	T1: 2–4wks Post-intervention	CB-PTSD (PPQ)	Positive Tx effect on CB-PTSD symptoms at T1.	Good (28)
Educational Interventions
Ahmadpour (2022)125	IRN	RCT	N=106	Age, M=26yrs 13% University degree	Universal	1°	Birth Plan	2 sessions. Control: TAU	T1: Immediate PP T2: 4–6wks PP	CB-PTSD (PSS) PPD (EPDS) FoC (W-DEQ) Childbirth Experience (CEQ 2.0; DFS; SCIB)	Positive Tx effect on CB-PTSD and PPD symptoms, FoC, and childbirth experience at T1 and T2.	Good (26)
Gökje (2016)126	TUR	NRCT	N=90	Age, M = 26yrs 61% ≥ Bachelor’s degree	Universal	1°	Antenatal education	4 weekly group sessions (4 hrs each) Control: TAU	T1: 6–8wks PP	CB-PTSD (IES-R); FoC (WDEQ); Childbirth Self-efficacy Inventory	Positive Tx effect on CB-PTSD symptoms, FoC, and childbirth self-efficacy.	Good (22)
Slade (2020)61	UK	RCT	N=678	Age, M = 30yrs 89% White 89% Partnered	Targeted: DSM-IVR criterion A2	2°	Educational self-help strategies	Self-help materials reviewed after delivery Control: TAU	T1: 6–12wks PP	CB-PTSD (CAPS-5 * interview); Depression and anxiety (HADS); Attachment (MPAS); Feedback interviews	No Tx effect on CB-PTSD symptoms or CB-PTSD incidence rates. No Tx effect on PPD and anxiety, or mother-infant-bonding. Tx received as useful.	Excellent (31)
Mitchell (2018)63	AUS	NRCT	N=262	41% Caucasian 78% ≥Bachelor’s degree; 98% Partnered	Universal	3°	Compassion-focused self-help materials	Online resources (2 videos and an informational sheet on self-compassion) could be accessed ad libitum by women at ≤ 2 yrs PP Control: None	T1: Post-intervention (1mo later)	CB-PTSD (IES-R); Self-compassion (SCS-SF); Breastfeeding satisfaction (MBFES); Intervention Feedback	Positive Tx effect on CB-PTSD symptoms, intrusion, and hyperarousal; overall self-compassion and breastfeeding satisfaction. Tx received as helpful.	Poor (13)

Notes: Sample Types targeting DSM-IV and DSM-5 criteria pertain to CB-PTSD. The difference between DSM-IV criterion A and DSM-5 criterion A is that the latter removed the former’s additional component of “intense fear, horror, or helplessness.” Outcome Measures and corresponding Results report only significant Tx effects for primary outcomes (CB-PTSD) and secondary outcomes (e.g. PPD, anxiety, and mother-infant bonding) if such measures were assessed. Satisfaction with therapy also reported if assessed. If “Intervention Feedback” is listed in Outcome Measures, such feedback was obtained through qualitative interviews, surveys, and other unstructured methods. Numerical scores were converted to ordinal grouping; given our modified scoring system, we converted the established cutoff levels to percentages and applied them to our modified scoring system. Modified quality score ranges were, therefore, specified as: Excellent (29–31); Good (22–28); Fair (17–21); Poor (≤16).

Quality Scores: Excellent (29–31); Good (22–28); Fair (17–21); Poor (≤16).

Abbreviations:

^*= Clinician-Administered Assessment

Intervention Categories:

1°: Primary, delivered before childbirth

2°: Secondary, delivered after traumatic childbirth to reduce early signs of traumatic stress and buffer the development of full-blown CB-PTSD

3°: Tertiary, delivered in the months and years postpartum to lessen childbirth-related PTSD in affected women

Country Abbreviations:

TUR: Turkey

AUS: Australia

USA: United States of America

IRN: Iran

SWE: Sweden

DEU: Germany

ITA: Italy

UK: United Kingdom

CAN: Canada

CHE: Switzerland

ISR: Israel

Additional Abbreviations:

ASDS: Acute Stress Disorder Scale

BAI: Beck Anxiety Inventory

BDI-II: Beck Depression Inventory-II

CA: Corrected age

CBC: Cognitive Behavioral Counseling

CB-PTSD: Childbirth-related Post-Traumatic Stress Disorder

CBT: Cognitive Behavioral Therapy

CESD: Center for Epidemiologic Studies Depression Scale

CIS-Debriefing: Critical Incidence Stress Debriefing

CSE: Collective Self-Esteem Scale

DTS: Davidson Trauma Scale

ECS: Emergency Caesarean Section

EMDR: Eye Movement Desensitization and Reprocessing

EPDS: Edinburgh Postnatal Depression Scale

EQ5D: EuroQol 5 Dimensions

EW: Expressive Writing

FoC: Fear of Childbirth

HAM-A: Hamilton Anxiety Rating Scale

iCBT: Internet-based CBT

IES(−R): Impact of Events Scale (Revised)

LASC: Los Angeles Symptoms Checklist

M: Mean

Mdn: Median

MIBS: Mother to Infant Bonding Scale

MINI-I: Mini International Neuropsychiatric Interview

MSSS: Modified Social Support Survey

NBAS: Neonatal Behavioral Assessment Scale

NICU: Neonatal Intensive Care Unit

NRCT: Non-Randomized Controlled Trial

PBQ: Postpartum Bonding Questionnaire

PCL-5: PTSD Checklist for DSM-5

PDEQ: Peritraumatic Dissociative Experiences Questionnaire

PHQ-9: Patient Health Questionnaire

POBS: Perception of Birth Scale

PP: Postpartum

PPD: Postpartum Depression

PPQ: Perinatal Posttraumatic Stress Disorder Questionnaire

PSI: Parenting Stress Index

PSS: Parental Stressor Scale

PSS-SR: PTSD Symptom Scale – Self-Report Version

PTCI: Posttraumatic Cognitions Scale

QOLI: Quality Of Life Inventory

RCT: Randomized Controlled Trial

SADS-1: Schedule for Affective Disorders & Schizophrenia

SCL: Symptoms Checklist

SF-36: 36-Item Short Form Health Survey questionnaire

SOS: Significant Others Scale

SSC: Skin-to-Skin Contact

STAI: State-Trait Anxiety Inventory

Tx: Treatment

TES: Traumatic Event Scale

TES-B: Traumatic Event Scale – Delivery

TF-CBT: Trauma-Focused Cognitive Behavioral Therapy

UCS: Unscheduled Cesarean Section

WDEQ: Wijma Delivery Expectancy Questionnaire

d. Quality Assessment and Risk of Bias

A pair of two reviewers independently evaluated the quality of all trials using the modified Downs and Black 27-item checklist⁵¹ (Appendix A) for external and internal validity, subject and experimenter blinding, confounding bias, and statistical power, lending numerical quality scores and range terms (i.e., Excellent (29–31); Good (22–28); Fair (17–21); Poor (≤16)) (Table 1). Inter-rater reliability was 91%. Risk of bias assessment was conducted in accordance with the Cochrane Risk of Bias 2 (RoB 2) tool⁵³ for randomized trials and Cochrane Risk Of Bias In Non-randomized Studies (ROBINS-I).⁵²

e. Statistical Approach for Meta-Analysis

We calculated the pooled effect size of the between-group post-treatment differences in randomized studies for CB-PTSD symptoms as a continuous outcome with random-effects models, which allows for assuming heterogeneity.⁵⁵ Standardized mean differences (SMDs) with 95% confidence intervals (CIs) represented effect sizes.⁵⁶ Small samples were corrected with the Hartung-Knapp correction.⁵⁷ Heterogeneity was evaluated using Chi-square and I² statistic.⁵⁸ If a study had more than 1 control group for comparison, both comparisons were performed.

We examined pooled effects separately for secondary and tertiary preventions. We performed subgroup analysis by treatment modality (for modalities represented by 2+ trials) and treatment intensity (number of sessions: 1 session vs. >1 session). Publication bias was assessed by funnel plot and Egger’s test.⁵⁹ Sensitivity analysis was performed by RoB 2 risk of bias category (some concerns vs. high risk) and using the leave-one-out method.

To explore potential moderators of CB-PTSD symptoms change post-treatment, we performed univariate random-effects meta-regression in accord with Thompson and Higgins’ recommendations.⁶⁰ Moderator variables were treatment modality type, risk of bias category, outcome timepoint (in weeks), and treatment intensity (i.e., number of sessions). Each moderator was tested on a minimum of 8 studies.⁶⁰ To assess the models, we evaluated significant criterion of p<0.05 per each moderator, residual percentage of variation due to heterogeneity (I², Tau²) and proportion of between-study variance explained (adjusted R²). We performed a Monte Carlo permutation test to account for high false-positive rates associated with meta-regression models using 10,000 random permutations. The analyses were performed in R Studio 4.1.1 (R Foundation for Statistical Computing, Vienna, Austria).

Results

a. Study Characteristics

Detailed information about study characteristics is presented in Table 1. Of the 41 reviewed studies, 32 were randomized controlled trials (RCTs), and 9 non-RCTs, totaling 4,934 subjects. Trials were published between December 1988 and September 2023.

Treatment timing. 3 trials were primary preventive interventions delivered during pregnancy; 24 tested secondary preventions provided after childbirth but not later than 1 month postpartum, i.e., before a DSM-5 PTSD diagnosis can be confirmed;¹¹ and 14 trials involved tertiary prevention delivered >1 month postpartum in cases of full or subsyndromal CB-PTSD. Figure 2 provides a summary of the modalities reviewed for primary, secondary, and tertiary interventions.

Figure 2. Treatment approaches for childbirth-related PTSD prevention.

Primary, secondary, and tertiary preventive treatment approaches for CB-PTSD tested in the reviewed trials. Grey boxes indicate treatment modality, purple boxes highlight the most efficacious interventions, and white boxes indicate specific type of interventions. Trauma-focused expressive writing (TF-EW) for secondary prevention was tested in universal samples.

Treatment type. 37 trials were psychological therapies. They pertained to psychological debriefing (n=4); crisis intervention (n=1); trauma-focused therapies (n=15), i.e., cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and expressive writing about childbirth; memory consolidation/reconsolidation blockade (n=3); psychological counseling (n=5); mother-infant-focused therapies (n=4); and alternative approaches, i.e., visual biofeedback (n=1), mindfulness-based stress reduction (MBSR) (n=1), and music therapy (n=2). The remaining 4 trials were educational (Table 1).

Treatment response. CB-PTSD outcome was measured using validated patient self-administered questionnaires of PTSD symptoms specified to childbirth (n=36). Clinician diagnostic evaluations were less common (n=5). Duration of treatment effects primarily targeted short- or moderate-term (n=15, <2 months and n=19, 2–6 months, respectively). Several studies measured long-term effects (n=7, >6 months).

b. Quality Assessment and Risk of Bias Results

For RCTs, Downs and Black quality score⁵¹ ranged from Fair to Good for 31 trials (score, 18–28); 1 trial⁶¹ scored Excellent. For non-RCTs, scores ranged from Fair to Good for 7 trials (quality score, 17–23); 2 trials^62,63 scored Poor (Table 1). For RCTs, Cochrane (RoB 2) risk of bias⁵³ (Figure 3) revealed that no trial was judged low risk of bias on all 5 domains; 7 were considered low-risk on 4 domains; 9 low-risk on 3 domains. The remaining 16 were judged low-risk on <=2 domains (Figure 3). Risks primarily entailed inadequate subject and experimenter blinding (Domain 2), an inherent limitation in psychological therapies, and treatment outcome measurement using patient self-report (Domain 4). For non-RCTs, using Cochrane ROBINS-I⁵² (Figure 4), no trial was judged low risk of bias on >= 6 domains; 2 were considered low-risk on 5 domains; 4 low-risk on 4 domains. The remaining 3 were judged as low-risk on <=3 domains (Figure 4).

Figure 3. Risk of bias for randomized trials for CB-PTSD prevention.

Risk of bias assessment by intervention modality for all randomized trials targeting CB-PTSD prevention or treatment of CB-PTSD using the Cochrane RoB 2 tool.⁵³

Figure 4. Risk of bias for non-randomized trials for CB-PTSD prevention.

Risk of bias assessment by intervention modality for all non-randomized trials targeting CB-PTSD prevention or treatment of CB-PTSD using the Cochrane ROBINS-I tool.⁵²

c. Synthesis of Results

Psychological therapies are detailed in Table 1.

Debriefing.

Debriefing, with origins in combat settings, is an immediate brief intervention designed to manage normal stress reactions after a traumatic event.^64–67 Debriefing for CB-PTSD was tested in 4 large-scale RCTs as secondary prevention delivered primarily during maternity hospitalization stay in the form of midwife-led dialogue about delivery-related emotions.^68–71 Although valued by patients, there is insufficient evidence in favor of debriefing delivered in the days following childbirth.^68–71 A single session after a healthy delivery was not associated with better outcomes regarding CB-PTSD symptoms^68,69 or diagnostic prevalence versus treatment as usual (TAU).⁶⁹ Women with medical interventions reported more negative perceptions of childbirth after debriefing.⁶⁸ Likewise, 2 sessions (10 days and 10 weeks) after complicated (operative) deliveries yielded no better effects.⁷¹ In contrast, a single session following traumatic childbirth experiences resulted in moderate-term sustained improvements in CB-PTSD symptoms.⁷⁰

Evidence in support of debriefing as a tertiary prevention is limited. In a non-RCT, a single session outside the postpartum period (~16 weeks postpartum) showed favorable outcomes.⁷²

Crisis Intervention.

Crisis intervention delivered in the acute aftermath of a trauma event primarily entails providing information about the impact of stress and learning coping strategies to stabilize emotions.⁷³ 1 non-RCT employed crisis intervention for CB-PTSD. A single group session provided to mothers during infant neonatal intensive care unit (NICU) stay coupled with brief psychological aid and intense support during critical times was associated with fewer CB-PTSD symptoms at hospital discharge compared with TAU (hospital minister counseling).⁷⁴

Trauma-Focused Psychological Therapies.

Trauma-Focused Psychological Therapies are structured, manualized therapies that directly focus on the processing of traumatic experiences and memories to facilitate fear extinction.⁷⁵

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a conventional first-line therapy for PTSD. It incorporates psychoeducation, behavioral exposure, and cognitive restructuring to challenge cognitive distortions and reorient adaptive thoughts.⁷⁵ TF-CBT (or elements) was tested in 3 RCTs^70,76–78 and 1 non-RCT⁷⁹ as a targeted early intervention usually delivered in the hospital to women with birth trauma with or without infants admitted to the NICU; and in 2 RCTs^80,81 as tertiary prevention delivered via the internet in the months and years postpartum to women with clinical symptoms of CB-PTSD.

A single cognitive behavioral counseling (~50-min) session 48 hours postpartum resulted in moderate-term sustained reductions in CB-PTSD symptoms compared with TAU and debriefing.⁷⁰ Sequential (3–9) sessions focused on NICU stressors resulted in sustained positive effects on CB-PTSD and PPD symptoms compared with standard care.^76–78 Six group sessions delivered in the NICU were also associated with symptoms improvement in a small non-RCT.⁷⁹

TF-CBT as a tertiary approach delivered via the internet revealed mixed findings.^80,81 When delivered ~2.8 years postpartum to women with provisional CB-PTSD, the therapy improved CB-PTSD symptoms and quality of life.⁸⁰ When delivered 2–4 months after medically (severely) complicated delivery, the therapy was not associated with better outcomes.⁸¹

Eye movement desensitization and reprocessing (EMDR) is a conventional first-line therapy for PTSD. Patients are instructed to briefly focus on the trauma memory while simultaneously experiencing bilateral (eye) stimulation to reduce the vividness and emotions associated with the memories.^82,83 EMDR for CB-PTSD was tested in 1 RCT⁸⁴ as secondary single-session preventive intervention in women at high risk for CB-PTSD and in 1 RCT⁸⁵ and 2 non-RCTs^62,86 as tertiary prevention in women with full or subsyndromal CB-PTSD.

As an early intervention, a single (90-min) session delivered during maternity hospitalization stay reduced CB-PTSD symptoms and subjective distress regarding future deliveries in women with acute traumatic stress, and had sustained effects;⁸⁴ however, there were no effects on CB-PTSD diagnosis incidences.⁸⁴ As a later intervention in affected women, consecutive sessions in the months and years postpartum resulted in sustained treatment benefits.^62,85,86

Expressive writing (EW) following trauma entails a brief structured intervention delivered by a non-professional in which individuals repeatedly write narratives about their trauma in response to specified instructions, with a focus on related thoughts and feelings.^87–89 The intervention was tested in 4 RCTs^90–93 as a secondary universal prevention delivered 48–96 hours postpartum and in 2 RCTs^94,95 as tertiary prevention in women with infants in the NICU.

Following childbirth, a single (10–15-minute) session entailing writing about childbirth, compared with no writing^90,91 or writing about daily events,⁹² resulted in reduction in CB-PTSD^90–92 (re-experiencing and avoidance) and PPD^92,93 symptoms with moderate-term sustained effects. For women with higher stress at baseline, 2 sessions of TF-EW about childbirth produced the greatest reduction in CB-PTSD and PPD symptoms.⁹³

In the months and years postpartum, consecutive (3–4) writing sessions about childbirth and infant hospitalization resulted in positive treatment effects, with sustained short- and moderate-term improvement in CB-PTSD^94,95 and PPD⁹⁴ symptoms.

Memory Consolidation (Re-consolidation) Blockage.

In the hours post-trauma, as well as during memory retrieval, the memory of the trauma is malleable.^39,96,97 Accordingly, cognitive tasks with high visuospatial demands, such as playing Tetris, may selectively disrupt the sensory elements of the memory and prevent PTSD or lessen symptoms.

Engaging in a single (15-min) Tetris session was tested in 2 RCTs^98,99 as a secondary prevention within 6 hours after emergency/unscheduled Cesarean delivery. The task was associated with reduction in intrusive memories and acute stress versus TAU in the week following the intervention. However, findings were mixed in terms of sustained effects in CB-PTSD symptoms.^98,99 No advantage for the treatment was found using clinician evaluations.⁹⁹

Evidence of Tetris’s benefit as tertiary prevention, although promising, is limited. In a non-RCT of a single session ~2 years postpartum, 58.8% of affected women experienced ≥50% reduction in CB-PTSD symptoms; no subject met diagnosis post-intervention.¹⁰⁰

Psychological Counseling.

Psychological counseling is an unstructured or semi-structured approach focused on empathic and nonjudgmental listening and support.^101,102 This intervention was tested in 4 RCTs^103–106 as secondary prevention midwife-led dialogue after traumatic childbirth, delivered in the hospital, focused on acceptance of childbirth experiences, emotions expression, problem solving, and baby care-related discussion.

Counseling performed 24–72 hours postpartum had positive effects when delivered to women who met PTSD DSM criteria for trauma exposure (e.g., threat to life).^103–105 Single-session counseling (coupled with a brief follow-up) versus TAU was associated with reduction in CB-PTSD and PPD symptoms^103–105 and greater confidence about future pregnancies, with sustained moderate-term effects^104,105 but did not improve diagnostic incidences.¹⁰⁵ Likewise, 2 consecutive sessions delivered in the hospital after emergency Cesarean (coupled with 2 follow-up sessions) were associated with fewer CB-PTSD symptoms, and more positive childbirth appraisals, with sustained moderate-term effects; however, the treatment was insufficient in cases of substantial acute stress.¹⁰⁶ Counseling as a tertiary prevention following emergency Cesarean did not show sustained benefits based on a single RCT.¹⁰⁷

Mother-Infant-Focused Interventions.

The immediate period after delivery is thought to offer a unique time for boosting mother-infant connection.¹⁰⁸ Women with CB-PTSD show impairments in the formation of mother-infant bonding,^18,29,30 underscoring the potential for an early mother-infant-focused intervention to offer benefits for this population. Mother-infant-focused therapy ranging from skin-to-skin to dyadic intervention was tested in 2 RCTs^109,110 as early intervention following traumatic childbirth and 2 RCTs^111,112 as tertiary prevention for mothers with preemies.

1-hour-long skin-to-skin during the ‘magical’ immediate postpartum versus routine skin-to-skin in women meeting DSM PTSD Criterion A was associated with sustained moderate-term effects on CB-PTSD symptoms.¹⁰⁹ Likewise, 5 brief observation/play sessions of mother-preemie outside the postpartum increased maternal sensitivity and infant cooperation, and decreased CB-PTSD symptoms, with sustained long-term effects.¹¹¹ In contrast, early intervention of multi-sensory stimulation delivered in the NICU was not superior to kangaroo care or TAU,¹¹⁰ nor was an intervention focused on reading and responding to infants’ cues.¹¹²

Alternative Interventions.

Alternative therapies for PTSD that were tested for CB-PTSD include biofeedback^113,114 tested as a primary prevention in a non-RCT;¹¹⁵ mindfulness-based stress reduction (MBSR)¹¹⁶ tested as a secondary prevention in an RCT;¹¹⁷ and music therapy^118,119 tested as secondary and tertiary prevention in 2 RCTs.^120,121

As a universal approach, visual (~5-minute) biofeedback ultrasound during the second stage of labor versus TAU was associated with increased maternal-newborn connectedness, and in turn reduced acute stress and CB-PTSD symptoms 1 month later.¹¹⁵ As an early intervention following prematurity, consecutive MBSR sessions on attention to present-moment sensations and affective states to increase control, resulted in short-term sustained effects in improvement in CB-PTSD symptoms compared with TAU.¹¹⁷ Likewise, consecutive sessions of live music delivered by music therapist in the NICU improved CB-PTSD and PPD symptoms at hospital discharge.¹²⁰ Daily non-verbal music listening sessions in the NICU resulted in symptom improvement.¹²¹

Educational Interventions.

Educational interventions during pregnancy and following childbirth are provided by midwives and nurses and/or entail self-help materials.^122–124 Universal primary prevention approach during pregnancy was tested in 1 RCT¹²⁵ and 1 non-RCT;¹²⁶ the use of self-help materials following birth trauma was tested in 1 RCT;⁶¹ and as tertiary prevention in 1 non-RCT focusing on self-help compassion.⁶³

Consecutive birth plan sessions in third-trimester pregnant women versus TAU resulted in less fear of childbirth, improved childbirth experience, and fewer CB-PTSD and PPD symptoms in the weeks post-delivery.¹²⁵ Similarly, consecutive educational group sessions during pregnancy were associated with less fear of childbirth, more self-efficacy, and fewer CB-PTSD symptoms in the weeks postpartum in a non-RCT.¹²⁶

As secondary prevention, self-help materials alone were insufficient to reduce CB-PTSD incidences in women who had birth trauma.⁶¹ In contrast, online self-compassion-focused materials provided universally and outside the postpartum period were associated with increased self-compassion and decreased CB-PTSD symptoms.⁶³

Meta-analysis Results

Secondary prevention. Random-effects meta-analysis (Figure 5) showed statistically significant moderate effect size (SMD =−0.67; 95% CI −0.92, −0.42) favoring secondary preventions (n=2,476) compared with control interventions (n=2,523). Heterogeneity level was high (I²=90%), indicative of high variations in treatment outcomes between studies. The identified source of heterogeneity was treatment modality (explained 25.63% of variance). Psychological counseling (SMD =−0.91; 95% CI −1.61, −0.21) and trauma-focused interventions (SMD =−0.95; 95% CI −1.50, −0.40) showed statistically significant larger effects in reducing CB-PTSD symptoms; debriefing had small effects (Figure 6). Single-session interventions showed moderate effects (SMD =−0.55; 95% CI −0.91, −0.18) and were not statistically different from multiple-sessions trials (SMD =−0.80; 95% CI −1.19, −0.41, p=0.29) (Figure 7). Differences between studies in treatment effects were not related to timepoint measurement (p=0.42, Supplementary Figure 1) or risk of bias (p=0.24, Supplementary Figure 2). Publication bias was not identified (Egger’s test p =0.06, Supplementary Figure 3), and sensitivity analysis showed no influential studies (Supplementary Figure 4).

Figure 5. Meta-analysis of secondary prevention trials for CB-PTSD.

Forest plot depicting the pooled effect estimates of CB-PTSD symptoms in the meta-analysis of 23 comparisons (n=4999). Each square represents the study-specific effect size, with the size of the square corresponding to the weight of the study in the analysis. Horizontal lines denote the 95% confidence interval (CI) for each study, and the diamond represents the overall pooled effect estimate with its 95% CI. The vertical line at the null value (mean difference of 0) indicates no effect. Studies favoring the intervention are to the left of the line, while those favoring the control are to the right. Heterogeneity among studies is assessed by the I² statistic. For the Deforges 2023 study, Mean and SD were generated from symptom counts (Figure 2 from that paper) using the PlotDigitizer platform (https://plotdigitizer.com).

Figure 6. Subgroup analysis of secondary prevention trials for CB-PTSD by treatment modality.

Forest plot illustrating subgroup analysis for treatment modality within the meta-analysis. The squares represent the effect estimates for each subgroup. Horizontal lines indicate the 95% confidence interval (CI) for each subgroup. The diamonds represent the pooled effect estimates for each subgroup, and their width reflects the corresponding 95% CI. The vertical line at the null value indicates no effect. Subgroup-specific effects are compared (test for subgroup differences). Heterogeneity within subgroups is assessed by the I² statistic, providing insights into the consistency of effects across different subpopulations. Overall heterogeneity is also provided.

Figure 7. Subgroup analysis of secondary prevention trials for CB-PTSD by number of sessions.

Forest plot illustrating subgroup analysis for number of sessions (> 1 session) within the meta-analysis. The squares represent the effect estimates for each subgroup. Horizontal lines indicate the 95% confidence interval (CI) for each subgroup. The diamonds represent the pooled effect estimates for each subgroup, and their width reflects the corresponding 95% CI. The vertical line at the null value indicates no effect. Subgroup-specific effects are compared (test for subgroup differences). Heterogeneity within subgroups is assessed by the I² statistic, providing insights into the consistency of effects across different subpopulations. Overall heterogeneity is also provided.

Tertiary prevention. Random-effects meta-analysis (Figure 8) showed statistically significant small effect size (SMD =−0.37; 95% CI −0.60,−0.14) in favor of tertiary prevention treatments (n=414) compared with control interventions (n=399), with a relatively small between-study heterogeneity (I²=45%). Trauma-focused interventions (SMD =−0.45; 95% CI −0.91,0.00) showed a moderate effect size compared with mother-infant-focused interventions (SMD =−0.16; 95% CI −1.26,0.94) but no significant differences (Figure 9). Between-studies treatment effects were not associated with risk of bias (p=0.18, Supplementary Figure 5). No other source of heterogeneity was tested due to the small number of available studies. Sensitivity analysis showed no influential studies (Supplementary Figure 6).

Figure 8. Meta-analysis of tertiary prevention trials for CB-PTSD.

A forest plot is utilized to display the aggregated effect estimates of CB-PTSD symptoms in a meta-analysis comprising 9 comparisons (n=813). Each square corresponds to the effect size specific to each study, and its size reflects the study’s weight in the analysis. The 95% confidence interval (CI) for each study is represented by horizontal lines, and the diamond illustrates the overall pooled effect estimate alongside its 95% CI. The vertical line at the null value (mean difference of 0) signifies no effect. Studies favoring the intervention are positioned to the left of the line, while those favoring the control are on the right. The I² statistic is employed to assess heterogeneity among the studies.

Figure 9. Subgroup analysis of tertiary prevention trials for CB-PTSD by treatment modality.

A forest plot is presented to depict the subgroup analysis based on treatment modalities within the meta-analysis. Each square corresponds to the effect estimate for a specific subgroup, with horizontal lines indicating the 95% confidence interval (CI) for each subgroup. Diamonds represent the pooled effect estimates for each subgroup, and their width indicates the corresponding 95% CI. The vertical line at the null value signifies no effect. The comparison of subgroup-specific effects involves testing for subgroup differences. Heterogeneity within subgroups is evaluated using the I² statistic, offering insights into the consistency of effects across diverse subpopulations. Additionally, the overall heterogeneity is reported.

Comment

a. Principal Findings

This study, derived from 41 psychological and educational clinical trials, addresses an unmet clinical need concerning interventions aimed to lessen maternal psychological morbidity following medically complicated deliveries and/or potentially life-threatening childbirth experiences. Our systematic review and meta-analysis of primary, secondary, and tertiary preventive interventions (Figure 2) to reduce childbirth-related PTSD (CB-PTSD) onset and symptoms may guide evidence-based recommendations for effective therapies.

The main findings derived from randomized controlled trials (RCTs) demonstrate that brief psychological interventions delivered in the early postpartum, before CB-PTSD presents as a clinically diagnosable disorder, can aid in buffering traumatic stress in women who had a traumatic childbirth experience in which there is a threat (or potential threat), experienced or perceived, to the life of the woman or her infant. This often occurs in medically complicated deliveries. Early interventions with the most evidence-based support are trauma-focused therapies, which directly focus on processing the traumatic (birth) event, and midwife-led psychological counseling. In contrast, interventions delivered outside the postpartum period to women who likely endorse clinical CB-PTSD symptoms or met diagnosis reveal relatively small treatment effects. Knowledge of primary preventions is limited.

Evidence supports the feasibility and sustained positive effects of brief postpartum therapies targeted to women who had birth trauma, which are often performed during maternity hospitalization stay. Positive treatment responses are found following a single session. Although psychological debriefing or self-help materials may not work,^43,66 dialogue-based psychological counseling led by a midwife near bedside and conventional trauma-focused CBT, which is first-line treatment for general PTSD, as well as writing about the traumatic (childbirth) experience (termed expressive writing), appear beneficial based on large RCT studies. The latter could be relevant in low-resource settings, as it does not require a professional provider. What remains unclear is whether these therapies have efficacy as standalone treatments for women with severe maternal morbidities, and whether they can reduce CB-PTSD diagnosis incidence.

Other potentially promising early interventions warrant more research due to insufficient empirical scrutiny. Non-trauma-focused therapies such as memory consolidation blockage, involving interventions assumed to interfere with memory consolidation or reconsolidation processes, via engaging in Tetris, a low-demand cognitive task, or mindfulness-based stress reduction (MBSR) may be preferred by patients, as they do not require to directly confront the memory of the trauma. Mother-infant-focused interventions delivered during the “sensitive period” following childbirth may offer an exciting dual mechanism of actions in which improvement in CB-PTSD symptoms could be mediated via improved mother-infant bonding.¹²⁷

Interventions for the indication of CB-PTSD delivered outside the postpartum with the goals of lessening symptoms and improving functioning of affected women who may suffer from full-blown CB-PTSD may have substantial benefits for the developing child. Our analysis supports the combined benefits of trauma-focused therapies as tertiary preventions; however, evidence in support of each modality (CBT, EMDR, or expressive writing) is limited, and other treatment approaches (e.g., memory reconsolidation blockage, mother-infant-focused) are warranted to be tested.

b. Comparison with Existing Literature

A large body of research exists on approaches for the treatment of PTSD in non-postpartum populations.^75,128,129 Although psychological (trauma-focused) interventions are the gold standard, they suffer from high dropout rates;^130–133 one-third of patients are treatment non-responders.^130,134,135 Hence, the importance of intervening in the aftermath of trauma to buffer the development of persistent symptoms.

Currently, limited data are available on effective interventions to prevent PTSD.^48–50 Childbirth, however, provides a unique opportunity to deliver immediate treatment following trauma because of immediate access to postpartum patients. This review provides insight on promising preventive approaches for CB-PTSD, including the benefits of intervening in the first postpartum days, which, with more replicated and high-quality studies, could inform clinical recommendations. Our study expands previous reviews^45–50 by evaluating RCTs and non-RCTs published through September 2023 and performing a meta-analysis by timing of therapy, modality of therapy, and intensity of therapy. To our knowledge, this has not been performed before.

c. Strengths and Limitations

This review has evaluated clinical trials of primary, secondary, and tertiary prevention for CB-PTSD as universal and targeted interventions; and employed meta-analysis to determine combined effects of trials by treatment timing, treatment modality, and treatment intensity. Hence, we provide insight into what promising therapies and optimal timing for intervening may be, and which populations will benefit most. We also consider co-morbid conditions (e.g., peripartum depression) in the assessment of treatment efficacy. We use a well-validated quantitative approach based on the PRISMA guidelines⁵⁴ for study selection and data extraction, and incorporate two commonly used methods (i.e., Downs and Black Checklist⁵¹ and Cochrane Risk of Bias Tools)^52,53 to evaluate the quality of the trials and risk of bias, respectively.

Several limitations in this review are worth noting. Although we performed a sub-group meta-analysis by treatment modality to provide insight into treatment effects, only approaches represented by 2 or more studies were analyzed. Primary preventions were not included in the meta-analysis because of the small number of available RCTs. The reviewed studies had some concern about or high risk of bias due to inadequate subject and experimenter blinding, and reliance on women’s self-reports (although using validated questionnaires), which may be influenced by desirability bias; however, positive treatment effects were not related to studies’ degree of risk of bias or publication bias. A few studies did not have sufficient information about sample characteristics or clear time point of treatment assessment, which limited adequate quality review. Overall, the numbers of primary and tertiary prevention RCTs was small.

d. Conclusions and Implications

Maternal psychiatric morbidities are a leading complication of childbirth;^136–138 they impair maternal functioning, undermine infant development,^139–141 and result in heavy public health costs.^142–144 A significant portion of American women undergo complicated deliveries, and some experience or perceive childbirth-related life-threatening events, subsequently increasing risk for PTSD after childbirth (CB-PTSD).^{3,12,14,18,26,145} Treatment recommendations to guide routine perinatal care of at-risk women are lacking. Our review suggests that intervening in the early postpartum, and as soon as feasible, may offer a unique time window to lessen traumatic stress reactions and prevent CB-PTSD. As a first step, this requires early detection of women who had highly stressful, potentially life-threatening childbirth-related events, and may show acute stress,¹⁴⁶ to allocate resources to those at high CB-PTSD risk. A second step is ensuring treatment uptake. Brief therapies delivered before hospital discharge may offer effective therapy that also have the advantage of improving equity in postpartum care. Ultimately, an important clinical goal to be derived from future research entails implementation of interventions during pregnancy that promote opportunities for resilience and psychological growth, and readiness to cope with a traumatic birth experience, especially among women with a history of birth trauma. Antepartum approaches have the benefits of delivering therapy when women are in frequent contact with health providers and during a time of motivation for self-care.

Other areas for future research include replication of trials in rigorous RCT designs to minimize risk of bias by shifting from exclusive patient self-reports to also including diagnostics and mechanistic biomarkers; using well-powered samples; assessing long-term outcomes; and determining the ‘golden’ postpartum hours to optimize response. Additionally, testing adjunctive self-delivered remote therapies (e.g., physical exercise^147–149 and music) and alternative psychological (e.g., mindfulness¹⁵⁰ and yoga¹⁵¹) and pharmacological therapies that could promote maternal-infant bonding (e.g., intranasal oxytocin^127,152) will broaden treatment options and improve treatment scalability.

Ultimately, advances in neuroscience will likely provide a clearer picture of the mechanisms of CB-PTSD to inform personalized medicine approaches rather than “one size fits all”. However, before this knowledge is gained, providers are encouraged to consider on a case-by-case basis the available psychological treatment options to lessen maternal psychological burden after traumatic childbirth.

Supplementary Material

SuppTable1_Updated

Supplementary Table 1. List of acronyms and abbreviations used in this paper. (Note that Table 1 provides a separate list of acronyms and abbreviations specific to that table.)

SuppTable2_Updated

Supplementary Table 2. Glossary of terms used in this paper.

SupplementaryTable3_Revised

Supplementary Table 3. PICOS framework

SupplementaryTable4_Revised

Supplementary Table 4. Overview of search strategy

2

Supplementary Figure 1. Effect moderation by timepoint of outcome collection in secondary prevention trials. Bubble plot illustrating the results of meta-regression analysis for outcome timepoint and its impact on the pooled effect estimates of CB-PTSD symptoms across included studies. Each bubble represents an individual study, positioned based on its effect size and the corresponding value of timepoint in weeks. The size of each bubble is proportional to the weight of the study in the analysis. The line of best fit is presented (beta coefficient=0.008, p=0.42). The analysis reported no moderation effects of timepoint on the study outcome, thus not contributing to the observed heterogeneity.

3

Supplementary Figure 2. Sensitivity analysis of secondary prevention trials by risk of bias category. Analysis was performed in the meta-analysis of CB-PTSD symptoms. Each bar represents the pooled effect estimate for a specific risk of bias category (some concerns vs. high risk of bias), with error bars indicating the 95% confidence interval. The analysis explores the robustness of the overall findings by assessing the impact of varying levels of study quality on the pooled effect size. No discrepancies or patterns among different risk of bias categories were found, providing insights into the consistency of the statistically significant results.

4

Supplementary Figure 3. Funnel plot assessing publication bias in the meta-analysis of CB-PTSD symptoms in secondary prevention trials. Each point represents an individual study, and the funnel plot displays symmetry, suggesting a lack of publication bias. The horizontal axis represents the effect size, while the vertical axis illustrates the precision of the effect estimate (standard error). Egger’s test, a statistical assessment of publication bias asymmetry, was performed and found to be non-significant (p=0.06), providing further support for the absence of publication bias in the analyzed studies. The symmetrical distribution of points in the funnel plot and the non-significant result from Egger’s test enhance confidence in the reliability of the meta-analytic findings.

5

Supplementary Figure 4. Leave-one-out sensitivity analysis for the meta-analysis of CB-PTSD symptoms in secondary prevention trials. Each point on the plot represents the pooled effect estimate when one study is omitted from the analysis. The absence of a discernible outlier or significant impact on the overall effect size suggests that no single study exerts undue influence on the meta-analytic findings. This leave-one-out analysis underscores the robustness of the results and supports the conclusion that no individual study disproportionately shapes the observed effect, contributing to the overall stability and reliability of the meta-analysis.

6

Supplementary Figure 5. Sensitivity analysis of tertiary prevention trials by risk of bias category. In the meta-analysis of CB-PTSD symptoms, an examination was conducted. Each bar in the analysis depicts the combined effect estimate for a distinct risk of bias category (some concerns vs. high risk of bias), accompanied by error bars representing the 95% confidence interval. The investigation delves into the resilience of the overarching conclusions by scrutinizing the influence of diverse levels of study quality on the combined effect size. No discernible differences or patterns emerged across distinct risk of bias categories, shedding light on the uniformity of the statistically significant results.

7

Supplementary Figure 6. Leave-one-out sensitivity analysis of tertiary prevention trials. Sensitivity analysis through leave-one-out assessment was conducted in the meta-analysis of CB-PTSD symptoms within tertiary prevention trials. Each data point on the plot corresponds to the pooled effect estimate when a single study is excluded from the analysis. The lack of a conspicuous outlier or notable influence on the overall effect size implies that no individual study disproportionately affects the meta-analytic results. This leave-one-out analysis reaffirms the robustness of the findings, affirming that no specific study unduly shapes the observed effect. This contributes to the overall stability and reliability of the meta-analysis results.

Condensation Page.

1). Tweetable Statement:

Brief psychological interventions can buffer maternal post-traumatic stress symptoms after childbirth

2). Short Title:

Systematic Review and Meta-Analysis for Postpartum PTSD Prevention

3). AJOG At a Glance

A. Why was this study conducted?

• Traumatic, often life-threatening childbirth, experienced or perceived, can result in post-traumatic stress disorder (CB-PTSD) in a significant subset of women.

• Recommendations for preventive interventions or treatment are lacking.

• This systematic review and meta-analysis evaluated and analyzed results of 41 clinical trials for any type of CB-PTSD treatment published through September 2023.

B. What are the key findings?

• Brief psychological interventions delivered after traumatic childbirth can reduce maternal traumatic stress symptoms.

• Most supported interventions are trauma-focused therapies and midwife-led psychological counseling.

• Interventions in the early postpartum show larger effects than when delivered outside the postpartum.

• Evidence supporting primary preventive approaches is limited.

C. What does this study add to what is already known?

• This study provides knowledge of the modality, timing, and treatment duration of psychological interventions to mitigate CB-PTSD symptoms.

• Early psychological interventions could mitigate the adverse maternal mental health effects of birth trauma.