Midwife-led Childbirth Review and Psychological Outcomes in New Parents (CROWN)

Childbirth is a profound experience that may have long-term effects on maternal mental health and psychosocial functioning. While a positive childbirth experience may enhance psychological well-being, a negative childbirth experience has been associated with an increased risk of postpartum mental health difficulties, including post-traumatic stress disorder and postpartum depression.

In maternity care settings, a frequently used intervention aimed at processing childbirth experience is postpartum debriefing, which provides mothers with an opportunity to discuss their birth experience with a healthcare professional, most commonly a midwife. Postpartum debriefing provided by midwives has been integrated into maternity care in some countries and is offered as a targeted intervention to women after traumatic childbirth to reduce postpartum psychological morbidity. In some settings, however, postpartum debriefing is offered universally to all postpartum women; this is in line with qualitative studies showing that most women appreciate midwives initiating discussions about childbirth, listening to their experiences with empathy and support, and providing them with relevant information.

Reviewing childbirth experience with a supportive healthcare professional may help women facilitate understanding and integration of this emotionally and physically demanding event while gaining a sense of closure. Consequently, postpartum debriefing with a midwife may not only reduce the risk of psychiatric problems in women with traumatic childbirth experiences but may also be beneficial for the general population of postpartum women as a supportive intervention promoting psychological adjustment after childbirth. Following Sheen and Slade (2015), we refer to this type of supportive intervention as "childbirth review" to distinguish it from psychological debriefing provided following an adverse event.

Although postpartum debriefing is widely used in maternity care settings and recommended by policymakers, evidence regarding its effectiveness in improving postpartum mental health remains inconsistent and of limited quality. In addition, studies focusing on outcomes such as postpartum anxiety, parenting competence, sleep, social relationships, or future reproductive choices are lacking. Moreover, previous research has focused primarily on postpartum mothers, while largely omitting fathers present at childbirth.

This study aims to address these gaps by evaluating the effectiveness of midwife-led childbirth review (MLCR) offered to all postpartum women, as well as their partners present at childbirth, in order to improve postpartum psychological outcomes. MLCR employed in this study is based on the counselling model developed by Gamble and Creedy (2009) to support women with traumatic births and adapted for the general population of parents in the postpartum period. In this study, MLCR is conceptualized as a supportive discussion about childbirth experience intended to facilitate its understanding and processing in new parents.

MLCR will be delivered by midwives in a structured 45-60-minute session and will include review of the childbirth experience, active listening, emotional support, clarification of childbirth-related events and procedures when needed, and provision of information related to the birth. Mothers and fathers/partners will receive MLCR separately. To ensure intervention consistency, all participating midwives will complete standardized training and receive a detailed intervention manual before study initiation. Supervision procedures and an intervention fidelity plan will be implemented throughout the study. Standard postpartum care will not include the structured MLCR procedure or predefined intervention elements.

Participants (pregnant women and their partners) will be recruited during the third trimester of pregnancy from Bulovka University Hospital in Prague and University Hospital Brno. Data will be collected during late pregnancy, within the first postpartum week, at 6-8 weeks postpartum, and at 6 months postpartum.

Following childbirth and confirmation of study eligibility, women will be randomized to one of four groups: (1) MLCR within the first postpartum week, (2) MLCR at 6-8 weeks postpartum, (3) MLCR at both time points, or (4) standard postpartum care. Randomization will be stratified by key obstetric and psychological characteristics (parity, mode of birth, childbirth experience, psychiatric history). Fathers/partners will be assigned to the same study group as the mother.

The primary outcomes are maternal symptoms of postpartum depression and perinatal anxiety. The primary hypothesis is that mothers receiving any form of MLCR will report lower levels of symptoms of postpartum depression and perinatal anxiety at 6 months postpartum than mothers receiving standard postpartum care. In addition, repeated MLCR will be more effective than single-session MLCR, and early-only and later-only MLCR will differ in their effects on maternal postpartum depression and perinatal anxiety symptoms at 6 months postpartum. At 6-8 weeks postpartum, mothers who received MLCR within the first postpartum week are expected to report lower levels of depressive and anxiety symptoms than mothers who had not yet received MLCR. We will also examine whether baseline depressive and anxiety symptoms during pregnancy moderate the effects of MLCR on postpartum psychological outcomes.

Secondary outcomes for mothers include symptoms of general anxiety, parenting sense of competence, mother-infant bonding, sleep, relationship satisfaction, perceived stress, birth experience, childbirth-related post-traumatic stress symptoms, observed mother-infant interaction quality, and future reproductive choices. Hypotheses tested for secondary outcomes in mothers correspond to those for the primary outcomes.

Data from fathers will be analyzed separately as secondary analyses, as we expect a substantially smaller sample size for fathers. Outcomes/hypotheses related to paternal data will parallel those for maternal data.