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Midwife-led debriefing after operative birth: four to six year follow-up of a randomised trial [ISRCTN24648614]
© Small et al; licensee BioMed Central Ltd. 2006
Received: 27 October 2005
Accepted: 01 March 2006
Published: 01 March 2006
There is little evidence that single-session debriefing is effective in reducing adverse mental health outcomes after trauma. Few trials have included long-term follow-up, but two also suggest possible negative effects of debriefing. We aimed to assess longer-term maternal health outcomes in a trial of midwife-led debriefing following an operative birth, given that findings at six months could not rule out a possible adverse effect of debriefing.
Four to six years after participating in a midwife-led trial of debriefing following an operative birth, 1039/1041 women were mailed a questionnaire containing the Edinburgh Postnatal Depression Scale (EPDS) and the SF-36 health status measure.
Responses were obtained from 534 women (51.4%). Responders from the two trial groups remained comparable 4–6 years postpartum. No significant differences on maternal health outcomes were found between the trial groups.
In the longer term, maternal health status was neither positively nor adversely affected by the experience of debriefing, despite a hint of adverse effects at six months postpartum. Short debriefing interventions have not proven effective in improving mental health outcomes for women following childbirth.
Debriefing to reduce adverse mental health outcomes after traumatic events has been in widespread use for many years. Yet evidence for the effectiveness of brief or single-session debriefing is lacking . Moreover, longer-term outcomes of debriefing have been reported in only three trials (at 12 months,  13 months  and three years ) and in two of these, adverse outcomes were more common in the group receiving debriefing.
Six randomised trials of debriefing have now been offered to women after birth [2, 5–9]. All have focused on improving maternal mental health outcomes, recognising the potentially traumatic nature of the birth experience, at least for some women. Consistent with trials of brief debriefing interventions in other settings, four of the six trials found no benefit. Both of the two smallest trials, which showed positive effects of debriefing, reported unusually high levels of depression in the control arms (55%  and 32% ). In the latter trial , women were eligible for inclusion only if they reported experiencing fear for their own or their baby's life during labour or fear of serious injury or permanent damage. This selection of women with trauma symptoms might also explain the higher levels of subsequent depression. However, given the active identification of women reporting trauma symptoms, it is impossible to rule out adverse effects of assignment to a control group who were offered standard care.
We report here the four to six year outcomes of a midwife-led trial of debriefing for women who experienced an operative birth. Findings at six months postpartum demonstrated no benefit of debriefing in improving maternal mental health outcomes . On the other hand – and of concern – the possibility could not be ruled out that debriefing may have contributed to emotional health problems in the intervention group. This prompted longer-term follow-up of participants.
Ethics approval for the longer-term follow-up of trial participants was obtained from the recruiting hospital and the auspicing university ethics committees. Follow-up questionnaires were posted to 1039/1041 recruited participants. The questionnaire included the same outcome measures as the original trial questionnaire: the Edinburgh Postnatal Depression Scale (EPDS) and the self-report SF-36 health status questionnaire.
The initial mail-out of the postal questionnaire, and two reminder postcards to the contact addresses obtained at recruitment, resulted in the return of 322 completed questionnaires (31.6%). Extensive telephone follow-up of women who had not responded was then undertaken, again utilising information obtained at recruitment. Upon contact and agreement to participate, the offer of sending a second questionnaire was made. A significant minority were contactable at the same phone number, though at a new address, and so had not received the first questionnaire. Tracing of all women whose questionnaires were returned to sender, or were not contactable at the listed phone number, was also undertaken via the current electoral roll and telephone directories, and new questionnaires were sent to those women who could be traced to a new address. With specific ethics approval, we also initiated a new telephone contact procedure for identifying study participants from women with the same name but several possible new addresses. After this extensive tracing and follow-up, 534 women (51.4%) responded. Not all the women who could be contacted by telephone agreed to participate; some of those who did subsequently failed to return questionnaires. We did not re-contact these women to collect data from them by telephone, mostly because of a lack of resources. There were 264 responders from the debriefing arm and 270 from the standard care arm.
Recruitment characteristics of responders* and non-responders at 4–6 years
Characteristic (denominator: debriefing/standard care/non-responders)
Method of index (operative) birth (257/264/507)
Maternal age (256/264/507)
Marital status (257/264/507)
Cohabiting (de facto)
Separated, divorced, widowed
Secondary education (256/263/505)
Completed year 12
Less than year 12
Tertiary education (256/264/504)
Degree or diploma
Other or none
Family Income ($AUD) (248/254/484)
Pension or benefit main income (255/262/484)
Health insurance status (257/263/506)
Of the women responding at four to six years, there was no significant difference between the trial arms in the proportions who had scored as depressed at six months postpartum: 35/81 (43.2%) responded from the debriefing arm and 34/65 (52.3%) from the standard care arm; OR = 0.69; 95% CI: 0.34–1.41).
Maternal health outcomes at four to six years postpartum
* Probable depression (Score ≥13) n and %
OR = 0.94
CI: 0.58 to 1.53
* Mean score (SD)
t = -0.94
CI: -1.37 to 0.49
Women's report of depression as a problem in previous four weeks n and %
OR = 0.95
CI: 0.54 to 1.65
SF-36:Mental & Physical Health
Mental Component Score (MCS) Mean (SD)
t = 0.86
CI: -1.05 to 2.69
Physical Component Score (PCS) Mean (SD)
t = 0.30
CI: -1.21 to 1.64
Taken together, these follow-up findings are reassuring. Debriefing after an operative birth appears to have no longer-term adverse effects on women, despite a hint of this at the initial follow-up at six months postpartum. However, no benefits of debriefing emerged in the longer-term, a finding that further reinforces the conclusion that short debriefing interventions have not proven effective in improving mental health outcomes for women following childbirth.
Our thanks to the women who participated in the trial, the NHMRC for funding the longer-term follow-up and to Maggie Flood, Michelle Kealy and Michelle Kingston, who assisted in data collection and management.
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