A proportion of women reports all three aspects of post-traumatic stress type symptoms following childbirth with many more reporting some components. A broader conceptualization of post-partum distress which takes account of the impact of labour is required. There may be opportunities for prevention through providing care in labour that enhances perceptions of control and support.

HV training was effective compared with HV usual care in reducing the proportion of at-risk women with a 6-month EPDS score > or = 12, with a wide confidence interval for the estimated intervention effect, suggesting that the true treatment effect may be small. The effect remained for 1 year. The economic evaluation demonstrated that the HV intervention was highly likely to be cost-effective compared with the control. There was no difference in outcomes between the CBA and the PCA groups.

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Stigma and the wider social context should be considered when supporting people with fertility problems. Greater disclosure may be associated with higher distress in women.

Objective To evaluate benefits for postnatal women of two psychologically informed interventions by health visitors. Design Prospective cluster trial randomised by general practice, with 18 month follow-up. Setting 101 general practices in Trent, England. Participants 2749 women allocated to intervention, 1335 to control. Intervention Health visitors (n=89 63 clusters) were trained to identify depressive symptoms at six to eight weeks postnatally using the Edinburgh postnatal depression scale (EPDS) and clinical assessment and also trained in providing psychologically informed sessions based on cognitive behavioural or person centred principles for an hour a week for eight weeks. Health visitors in the control group (n=49 38 clusters) provided usual care. Main outcome measures Score ≥12 on the Edinburgh postnatal depression scale at six months. Secondary outcomes were mean Edinburgh postnatal depression scale, clinical outcomes in routine evaluation-outcome measure (CORE-OM), state-trait anxiety inventory (STAI), SF-12, and parenting stress index short form (PSI-SF) scores at six, 12, 18 months. Results 4084 eligible women consented and 595 women had a six week EPDS score ≥12. Of these, 418 had EPDS scores available at six weeks and six months. At six months, 34% women (93/271) in the intervention group and 46% (67/147) in the control group had an EPDS score ≥12. The odds ratio for score ≥12 at six months was 0.62 (95% confidence interval 0.40 to 0.97, P=0.036) for women in the intervention group compared with women in the control group. After adjustment for covariates, the odds ratio was 0.60 (0.38 to 0.95, P=0.028). At six months, 12.4% (234/1880) of all women in the intervention group and 16.7% (166/995) of all women in the control group had scores ≥12 (0.67, 0.51 to 0.87, P=0.003). Benefit for women in the intervention group with a six week EPDS score ≥12 and for all women was maintained at 12 months postnatally. There was no differential benefit for either psychological approach over the other. Conclusion Training health visitors to assess women, identify symptoms of postnatal depression, and deliver psychologically informed sessions was clinically effective at six and 12 months postnatally compared with usual care. Trial registration ISRCTN92195776. INTRODUCTIONPostnatal depression is a global problem and an important public health issue. About 13% of women experience depression during the first postnatal year, 1 yet there are problems in recognition because its clinical assessment is complex. There can be serious consequences for the mother, her child, 2 and family and a risk of suicide (the leading cause of maternal death in England and Wales) and infanticide in some severely depressed mothers.3 Fathers are also more likely to be depressed if their partner is depressed, 4 and the children of fathers who experience depression in the postnatal period are at increased risk of behaviour problems. 5In primary care, psychological interventions are as clinically effective in the management of depression...

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Objective Caesarean section rates are rising dramatically in the UK. It has been estimated that they have increased from 10% to 22% of all births over 15 years. A Swedish study has suggested that fear of childbirth during pregnancy may increase the risk of emergency caesarean section. The aim of this study is to identify whether fear of childbirth can predict the occurrence of emergency caesarean section in a UK sample. Design A prospective design using between-group comparisons.Setting Sheffield, S. Yorkshire, UK.Sample Four hundred and forty-three pregnant women, recruited at 32 weeks of gestation, over 16 years of age.Methods Participants completed self-assessment, postal questionnaires assessing fear of labour and anxiety using the Wijma Delivery Expectancy Scale (W-DEQ) and the Speilberger State Trait Anxiety Scale (STAI), together with their expectations about their mode of delivery. Delivery information was gathered via birth summary sheets. Main outcome measure Mode of delivery.Results Emergency caesarean section was associated with previous caesarean section, parity, age and a score reflecting medical risk, but not fear of childbirth or anxiety measures. There were no differences in fear between women experiencing spontaneous-vertex, forceps/ventouse, emergency or elective caesarean deliveries. The W-DEQ was factor analysed and was found to measure four distinct domains: fear, lack of positive anticipation and the degree to which women anticipate isolation and riskiness in childbirth. However, these individual factors also failed to contribute to the prediction of mode of delivery. Primiparous women in the UK sample showed highly elevated fear scores when compared with a Swedish sample. Such discrepancies were not found for the multiparous sample. Conclusions Fear of childbirth during the third trimester is not associated with mode of delivery in a UK sample. Possible cross-cultural differences are discussed.

Emotional, medical and control aspects of labour were explored in 81 primiparous women. Expectations were assessed antenatally and compared with postnatal reports of experiences. Expectations of positive emotions were significantly greater than experience while negative emotional expectations were paralleled by experience. There was a major discrepancy between expectations and experiences of the occurrence of interventions, with the proportion of women expecting interventions being greatly exceeded by those actually undergoing such experiences. In addition, expectations concerning personal control together with the use and efficacy of breathing and relaxation exercises in labour were elevated in relation to experience. Positive emotional expectations were strong predictors of positive emotional experiences and unrelated to negative emotional expectations. Expectations in general were positively related to experience but the strength of the association was weak. Personal satisfaction (i.e. satisfaction with self) in labour was strongly associated with the ability to control panic and other aspects of personal control. The ability to control panic was mainly influenced by the use of exercises. Attenders and non-attenders at antenatal preparation classes showed no significant differences in their experiences or personal satisfaction levels. Possible explanations for this absence of impact are discussed together with issues concerning the relevance of psychological theory to midwifery practice and the need for greater integration.