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. 2021 Nov 24;16(11):e0258170. doi: 10.1371/journal.pone.0258170

Table 3. Study characteristics table.

Author Country & Setting Study Design
No of Participants/ Interventions
Trauma Exposure Intervention,
Dosage & Timing
Comparison Follow-up Outcome Measures Adverse
Effects
Participant Subjective Experience
Results Comments
Abdollahpour (2019) [41] Hospital
Iran
RCT
3xarm
Parallel
design
N = 193
Cont 86:
CBT 53:
De-Bf 54
PP
Cntl = 81
CBT = 47
Debrief = 51
(Inc) Experienced a traumatic birth within the previous 48hrs, Qualified for PTSD criterion A DSM-5 as assessed by screening scale. Face to Face Debriefing,
cognitive behavioural counselling
Dosage:
1 x 40-60min administered within first 48hrs following birth.
Mother provided with counsellor’s phone number.
Interventions delivered by midwife (MSc. midwifery counselling).
3 x groups
Cognitive behavioural counselling, debriefing,.
Control condition care as usual
4–6 wks
12 wks
IES-R (PTSD)
Traumatic birth defined as criterion A of PTSD DSM_V.
None reported Results in favour of CBT counselling and debriefing over control condition at 4–6 wks and 12 wks.
Sig diff between all groups at 4–6 wks and 12 wks (p < 0.001).
No significant difference between the two intervention groups 4–6 weeks after the intervention.
CBT counselling better than face to face debriefing
at 12 weeks in reducing post-traumatic stress symptoms
5 control, 6 CBT, 3 debriefing dropped out.
Intervention content unclear.*
DASS_21 (dep, anxiety, stress)
Stress coping strategy scale utilized for inclusion.
No secondary outcomes
Abdollahpour (2016) [42] Hospital Iran RCT
N = 84
ITT 42:42
PP 39:39
Women who had experienced an immediate traumatic birth before facilitation of the intervention.
Qualified for PTSD criterion A DSM-5 as assessed by 4 item scale.
Midwife facilitated baby’s natural instinctive response of 9 phases following birth.
Intervention delivered in the hour following the traumatic birth event.
Care as usual 4-6wks
12wks
IES-R None reported Sig diff in favour of intervention at 12 wks Reduction of PTSD symptomology. No secondary outcomes
Asadzadeh
(2020) [43]
Hospital Persia RCT
N = 90
PP 44:43
Qualified for criterion A DSM-5 within 72hrs following birth.
In the last trimester of pregnancy.
Score over 10 Edinburgh PN Depression Scale
Midwife led counselling intervention based on Gamble’s counselling intervention
Dosage:
1 x face-to-face counselling session and
1 x telephone counselling session 4 to 6 weeks after giving birth.
1st author/ PhD researcher trained in and provided the intervention.
Administered within 72 hrs following birth.
Care as usual 4 wks
6 wks
12 wks
DSM-5-criterion A for the qualifying traumatic event “diagnosis of traumatic childbirth scale”. Scale developed by the authors
PCL-5
EPDS
Hamilton anxiety rating scale
None reported Results in favour of Midwife led counselling over care as usual at 4-6wks and at 12 weeks in reducing post-traumatic stress symptoms, depression, and anxiety.
Chiorino
(2019) [44]
Milan Italy
Hospital setting
RCT
N = 37
PP 19:18
(Incl) Women have subjective experience of traumatic childbirth experience assessed subjectively and objectively by clinician.
Score ≥24 on the (IES-R);
Brief one to one EMDR intervention utilizing the Birth Trauma Protocol.
Dosage:
1 x 90 min session 90min
Conducted within first 72 hrs following traumatic birth experience.
Intervention delivered by clinical perinatal psychologist.
Care as Usual
Standard supportive Psychological consultation focusing on emotions experienced during childbirth difficulties with caregiving, breastfeeding and psycho-physical recovery.
Dosage– 1 x 90 min session
Performed by 4x psychotherapists at MSc level or higher with supervision.
6week and 12 week follow up by telephone. PTSD
symptoms
IES-R
Prevalence of participants asymptomatic
IES-R score <23)
PDEQ
EPDS
MIBS
None reported Results in favour of intervention in reduced presence of flashbacks at 12 wks follow up (p = 0.042)
Sig diff in overall PTSD symptoms in favour of intervention at 4- 6wks (p = 0.04) and 12 wk follow up (p = 0.03).
Difference in number of women asymptomatic at 4–6 wks (p = 0.02) Cramers V = 0.408).
No Diff at 12wks (p = 0.124)
MVAV suggests no interaction of outcome measures on effect size.
Presence of flashbacks also measured.
Gamble
(2005) [29]
Australia RCT
N = 103
PP 50:53
Women reporting a traumatic birth experience as determined by
Criterion A DSM-IV
Debriefing/face to face counselling.
Dosage:
1 x face to face session of 40–60 mins within 72hrs following birth
1 x telephone session 4-6wks post-partum.
Intervention delivered by midwife
Care as Usual 4–6 weeks postpartum and 3 months postpartum PTSD diagnosis and PTSD symptoms (MINI-PTSD)
EPDS
DASS-21, stress, anxiety
86% women rated intervention highly (above 8/10)
90% Women reported that opportunity to talk about birth should be within a few days following birth.
The remaining favoured 4 wks post-partum and,
2 x reported during pregnancy as the best time to discuss.
Results in favour of intervention at 3 months follow up.
Sig diff in PTSD total symptom scores at 3-month follow-up
Sig diff in Depression scores at 3 months follow up on the EPNDS
X2 [1] = 9.188, p = 0.002
Sig diff in depression scores at 3 months follow up on the DASS-21 13(X2 [1] = 7.549, p = 0.005).
Sif diff in stress scores at 3 months follow up on DASS-21 when compared with the control group (X2 [1] = 4.478, p = 0.029)
No statistical difference between groups in number of women meeting PTSD diagnosis at either 4 to 6 wks postpartum or three months postpartum. No significant difference in PTSD symptoms between groups at 4 to 6 weeks.
Horsch
(2017) [45]
Switzerland RCT
N = 56
ITT 29:27
PP 25:24
Mothers recruited on the ward following EmCS Taking part in a computerised visuospatial cognitive task within 6 hours following emergency caesarean section.
Dosage– 10-15minute of play and daily diary of intrusive memories.
Intervention delivered by midwife
Care as usual 1 wk and 1 month PTSD symptoms
Posttraumatic Diagnostic Scale (PDS)
ASDS stress
HADS anxiety
HADS depression
Intrusive memories diary
Perceived to be acceptable by women.
No reported harmful effects or serious incident was reported
No Sig diff between groups in post-traumatic stress disorder at one month (ITT)
Sig diff favouring intervention in PDS avoidance cluster symptom count at 1 month (p = 0.05)
Sig fewer intrusive traumatic memories at 1 week than control group (p = 0.017)
Sig diff favouring intervention in reduced re-experiencing symptoms at 1wk ASDS (p = 0.06)
No significant group differences in the ASDS total score or HADS Anxiety or Depression scores at 1wk or 1 month follow up.
Sig diff in PTSD diagnostic criteria at 1 month in per protocol analysis (p = 0.039)
Ryding
(1998) [46]
Sweden RCT
N = 50: 49 completed
Women following EmCS recruited via a hospital obstetrics and gynaecology department
No specific symptoms of PTSD
Counselling and psychoeducation intervention.
Delivered between 8 days to 1-month post-partum.
Delivered by Obstetrician with psychotherapy qualification.
Dosage: 4 x sessions
first consultation took ≥ 1 hour. The second to fourth meetings were 45 min.
Care as usual
Discussion with midwife and Doctor who performed Em CS a few days after delivery.
6 months post-partum IES
Prevalence of PTSD symptoms: mild <20 moderate 20–30 and severe (PTSD probable) score over 30
W-DEQ 20 fear of childbirth
SCL 35 mental distress
None reported Neutral
No sig diff between groups in post traumatic stress symptoms at 6 months post partum.
Sig Diff between groups in general distress at 6 months post partum.
No reported ethical approval.
Median scores reported SD not reported.
Ryding [47]
(2004)
Sweden RCT
N = 162:147 available at initial follow up
Women following EmCS recruited via a hospital obstetrics and gynaecology department
Severity criterion:
No specific symptoms of PTSD
Group counselling and education.
Delivered 1–2 months post-partum
Delivered by Psychologist and ward midwife.
4–5 women per group
Dosage: 2 x 2hr sessions with 2–3 wk interval.
Care as Usual
Invited to individual consultation with midwife following birth.
6 months post-partum IES
Prevalence of post-traumatic stress symptoms
IES>30
W-DEQ B
EPNDS
Feedback from participants:
Too few participants in the group.
Needed additional sessions.
Need to include fathers.
Neutral
No sig diff between groups in childbirth experience, post traumatic stress or depression.
No reported ethical approval.
Median reported
No mean diffs or p reported.
No baseline measures reported.
Shaw [48]
(2013)
USA
NICU
RCT
N = 105
62:43
Women who had developed symptoms of trauma, anxiety or depression following preterm birth.
Recruited from NICU
Women who scored above the clinical cut off on any instrument (BDI-II score over 20; BAI score over 16; SASRQ score over 3 for the required number of questions in 2 or more of the symptom categories) were invited into the intervention phase
TF-CBT and techniques to enhance parenting confidence twice a wk over 3-4wks.
2 x sessions conducted at bedside in NICU
4 x sessions in NICU
Session 1: developing rapport Psychoeducation.
Session 2: Cognitive restructuring
Session 3 Progressive muscle relaxation
Session 4: psychoeducation TF_CBT, session 5: trauma narrative session 6: infant redefinition.
Intervention conducted by unlicensed Doctoral candidates completing PsyD.
Dosage: 6 x 45-55min sessions
Active comparison of psychoeducation 14 days following intervention, 4-5wks after birth, 6 months following birth. DTS for DSM-IV
SASRQ stress
PSS:NICU
BAI
BDI
Beck depression & anxiety
Mini international neuropsychiatric interview (MINI-PTSD)
None reported Sig moderate effect in favour of TF-CBT at 4–5 wk follow up in trauma symptoms [d = 0.41, p = 0.23] and depression [d = 0.59 p< .001] Effect size between groups diffs before and after intervention not reported on.
No power calculation
Experimental and comparison groups unequal.
SD not reported.
Slade
(2020) [49]
UK
Online
RCT
N = 678
336: 342
Women who reported their current birth experience as traumatic assessed by DSM-V criterion A Psychological Self-help materials:
A brief info leaflet and a web link to a film.
Administered less than 3 months post-partum
Care as Usual 6–12 weeks Diagnostic and sub diagnostic PTSD CAPS-5
HADS anxiety & depression
MPAS quality of attachment, hostility, pleasure in interaction
DAS4
No adverse effects
Women viewed intervention favourably
Neutral
ZelKowitz
(2011) [50]
Montreal Canada
Hospital and home Setting
RCT
N = 121
48:50
Mothers singleton infant born weighing less than 1500 grams recruited from NICU. PTSD symptoms related to experience of premature birth. No specifier. 5x sessions in hospital (1–2 sessions per week over 3–5 wks) 1x telephone call 1 wk after discharge 1 x session at home 2–3 wks after discharge.
Delivered by psychologist or nurse
Total Dose 9–10 hrs
Mother consents by 4th wk following birth
Usual Care and general information about caring for an infant 4–6 weeks 6 months PPQ Perinatal PTSD Questionnaire
Not primary outcomes
None reported Neutral 48% of women intervention gp had PTSD scores in clinical range at baseline
52.5% women in CAU had PTSD scores within clinical range at baseline

ITT, Intention to Treat; PP, Per protocol; EmCS, Emergency Caesarean section; Los Angeles Symptom Checklist (LASC) The Perinatal Risk Inventory (PERI), Depression, Anxiety and Stress Scale (DASS_21), Davidson Trauma Scale (DTS), The Stanford Acute Stress Reaction Questionnaire (SASRQ), Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU), The Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Mini-International Neuropsychiatric Interview–Post-Traumatic Stress Disorder (MINI-PTSD), Post Traumatic Stress Diagnostic Scale(PDS, Acute Stress Disorder Scale (ASDS), Hospital Anxiety and Depression Scale (HADS), Minnesota Multiphasic Personality Inventory-2 (MMPI-2), Perinatal PTSD Questionnaire (PPQ), Traumatic Event Scale (TES), Clinician Administered PTSD Scale for DSM-5 Diagnosis (CAPS-5). The Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ form B), Impact of Event Scale & Impact of Event Scale Revised (IES & IES-R), Edinburgh Postnatal Depression Scale (EPDS), Peritraumatic Dissociative Experiences Questionnaire (PDEQ), Mother to Infant Bonding Scale (MIBS), Symptoms Check List (SCL) Multidimensional Parental Attachment Scale (MPAS), Dyadic Adjustment Scale, (DAS4).