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Randomised controlled trial.
Follow up period:
Six weeks and six months after giving birth.
Public hospital, Sydney, Australia.
268 couples, expecting their first child, who were in the late second or early third trimester of pregnancy. Exclusion criteria: non-English speaking or same sex couples.
Participants were randomly assigned to the treatment group (empathy; 89 couples), a non-specific control group (baby play; 78 couples) or control (101 couples). All groups consisted of the usual six weekly sessions covering pregnancy, birth, breastfeeding, and a short session on postnatal depression. The empathy group included an extra session on psychosocial issues related to first time parents which aimed to increase the couples’ understanding of each other’s concerns, provide them with strategies to deal with being new parents and help them overcome feelings of stress, isolation, or lack of confidence. Mail outs were sent during follow up to reinforce what was learnt in this extra session. The baby play group also received an extra session and mail outs on how to play with babies, to control for beneficial effects of extra contact or from focusing on life after the baby’s birth. Data were collected from all groups at baseline, six weeks, and six months by separate self-report and structured interview.
Self esteem (Coopersmith Self-Esteem Inventory); improved mood (Edinburgh Postnatal Depression Scale); increased competence (Parenting Sense of Competence); improved support (Significant Others Scale, Who does What/Who will do What?); and increased partner awareness (Partner Awareness Scale).
Patient follow up:
82% at six weeks after birth; 73% at six months after birth.
Among women, antenatal self-esteem was equivalent across the groups (low self-esteem, 31%; medium self-esteem, 33%; high self esteem, 35%). At six weeks after childbirth, women in the low self-esteem empathy group had significantly lower levels of distress and depression, and felt more competent than women with low self-esteem in either control group (see http://www.ebmentalhealth.com/supplemental for table). These beneficial effects were due to the women’s partners sharing the baby care and home tasks after the birth and being more aware of the new mother’s feelings. Women with medium and high self-esteem did not benefit from the empathy intervention. At six months, there was no difference between the women in the empathy group and the two control groups, as the mean scores had dropped to levels similar to the six week empathy group for all participants
A single session to increase a partner’s understanding of motherhood significantly reduces postnatal distress and depression in first time mothers with low self-esteem.
Postnatal depression affects a significant proportion of women who give birth. It can develop into a long term problem with many negative consequences. Prevention of postnatal depression is thus an important public health issue. Several attempts to identify effective prevention strategies have been made, but with limited success. Matthey and colleagues contribute to this literature by investigating the efficacy of a brief intervention designed for couples expecting their first child.
Their study is notable for two reasons. Firstly, they attempt to limit the problem of non-compliance by offering a single additional session to usual postnatal preparation classes. Non-compliance has been a limiting factor in several previous studies. Secondly, the authors attempt to identify a potential moderator (self-esteem) of the intervention’s effect. Few studies of mental health interventions consider important variables that may moderate the intervention’s effectiveness.
This study has important implications for clinical practice. Firstly, it demonstrates that women with low self-esteem are more distressed. This suggests that low self-esteem may not only be a vulnerability factor for later depression, but also an indicator of current depression. Secondly, the study shows that for women with low self-esteem, a simple intervention focused on couple related issues is effective for reducing distress. Although the distress of women not in the experimental condition also resolved, this occurred some 4½ months later. Any additional time spent in a depression free or low distress state contributes to improved quality of life.
The findings have good generalisability. They should be applicable to any woman and her partner who are expecting their first child and are attending parenthood classes. However, the findings likely do not generalise to multiparous women, women not living with their partner, and couples who do not attend parenthood classes.
The intervention appears to be feasible in any context that involves parenthood classes. It seems to offer a cost efficient approach to reducing maternal distress. The findings should change clinical practice. They suggest that interventions should be focused on those most vulnerable for postnatal depression—that is, women with low self-esteem. Furthermore, the findings suggest that couple focused issues are important to address in preparation classes. This rarely happens in current practice.
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Files in this Data Supplement:
- [View PDF] - Mean adjusted scores for women and their partners at 6 weeks after birth
For correspondence: Stephen Matthey, SWSAHS, Paediatric Mental Health Service, Elizabeth Street, Liverpool, Australia;
Sources of funding: the Commonwealth Department of Health and Family Services (Research Section), Australia and Karitane, Australia.