Co-design and feasibility testing of a midwife-led birth debrief: An implementation science project

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Midwives play a critical role in supporting and promoting psycho-social health by providing mental health education, counselling and screening. Often this includes a post-birth conversation, guided reflection, or debrief. Information about the effectiveness and experiences of specific and structured midwife-led birth debrief is scant. Aim: The aim of our study was to assess the perceived effectiveness, experiences and implementability of postnatal midwife-led birth debriefing intervention. Methods : A Type II hybrid effectiveness – implementation design, specifically convergent mixed methods combining quantitative descriptive statistics with qualitative thematic analysis, was employed to simultaneously evaluate the clinical impact of a birth debriefing guide and its implementation within one Australian tertiary maternity service. ‘Effectiveness’ participants included women who had given birth in the nine months prior to study commencement, and ‘implementation’ participants included midwives and managers. Data were collected between January and September 2025. Ethical considerations Approval to conduct the study was obtained from two Human Research Ethics Committees. Results: The ‘effectiveness’ sample comprised 105 postnatal women. Satisfaction with the midwife-led post birth debrief intervention was consistently high across all measured domains and across models of care. A history of mental illness (n=21) was positively and statistically significantly correlated with three debrief satisfaction components: understanding birth process (ρ=+0.224, p=0.036), feeling emotionally stronger (ρ=+0.213, p=0.050), and feeling emotionally cared for (ρ=+0.218, p=0.035). Three themes were derived from qualitative data to describe the positive and powerful impact of midwife-led birth debrief on women. In terms of implementability, midwives unanimously endorsed the standardised birth debrief as a valuable tool and emphasised the need for trauma-informed care as its foundation, and sustainability assessments by managers scored highly, confirming the feasibility of translating midwife-led birth debriefing into routine practice. Conclusions : This study highlights the significance of midwife-led birth debriefing in supporting women’s perinatal mental health during the liminal perinatal period and underscores its potential to inform maternity care practice, policy and impact. Perinatal mental health perinatal counselling birth debriefing midwifery Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The period spanning pregnancy, birth and postpartum is characterised by psychosocial as well as physiological changes. These changes are not always positive though: many women experience new or worsening mental ill-health during the perinatal period. There is currently a significant gap in the way information about perinatal mental health is collected in Australia, and therefore the Australian Institute of Health and Welfare (1), which collates and published all national perinatal data and related information, is unable to report on perinatal mental illness rates, screening practices, service utilisation, or outcomes. According to other organisations, 1 in 5 childbearing women experience anxiety and 1 in 7 experience depression (2, 3). Additionally, up to 30% of the perinatal population are thought to experience birth trauma (4). While the causes of diminished perinatal mental health are multifactorial, the birth experience itself is a recognised contributing factor (see for example 5). During the postpartum period, midwives play a vital role in supporting new mother’s psychosocial adjustments, (6) mother infant relationships (7) and a particular role in promoting mental health through education and screening (8). One aspect of the midwifery role is holding a conversation with a person about their birth experience, often called a birth debrief (BD). A decade ago, a Cochrane review (9) found no definitive evidence to support or reject psychological debriefing in relation to childbirth; consequently, midwife-led debrief was largely discontinued. Many smaller studies since, however, have demonstrated its promise (10) but despite this, midwife-led birth debriefing is still not commonly offered: in a recent study only 26% of women reported receiving a debrief from a midwife after giving birth, and 64.4% were unaware of what it is and what it entails, even though 80% expressed a desire for such conversations (11). This underutilisation and lack of awareness highlight a critical shortfall in postnatal emotional support services; it is also representative of the challenges health services face in translating and implementing evidence into care in a timely manner (12). Demonstrating the effectiveness of standardised midwifery-initiated birth debriefing is essential to ensure consistent, evidence-based support that helps women process their birth experiences, reduces psychological distress, and promotes positive maternal well-being, and exploring its implementability is important to identify barriers to its sustained uptake. Aim The aim of our study was to assess the effectiveness and feasibility of midwife-led birth debriefing. Objectives To implement a midwife-led birth debriefing intervention in an Australian maternity service. To report the perceived effect of the midwife-led birth debriefing intervention from women’s perspective. To report the implementability of the midwife-led birth debriefing intervention. Ethical considerations Approval to conduct the project was obtained from [redacted for peer review] Hospital and [redacted for peer review] University Human Research Ethics Committees. Setting This study was set at an Australian tertiary maternity service that supports 3 600 births per year to women cared for in a range of models including medically led, midwife-led and blended options. Methodology Context Analysis A focus group (FG) comprising midwives, managers and consumers was convened to guide the study. The FG’s first tasks were to conduct a needs assessment and a context analysis to gauge readiness of the practice environment for change. Once it was determined through conversation that there was an appetite for capturing the midwifery role in post-birth debriefing, the ‘Checklist to Assess Readiness for Implementation’ (‘CARI’ [16]) was used to guide the assessment of the study site’s change readiness. The CARI is a widely used framework to guide assessment of contextual determinants of implementation (16) and the purpose of having a range of stakeholders complete it for this project was to elicit barriers to and drivers for the adoption of the proposed innovative in the index practice setting from different viewpoints. Intervention and instrument development using ADAPT methods The basis for our intervention was a pre-existing validated and structured process called the ‘Traumatic Childbirth Counselling Intervention’, which was developed by Gamble and colleagues in (17). This original intervention was a midwife-led, brief telephone counselling approach that demonstrated its effectiveness in reducing PTSD, depression, and anxiety (18,17). A recent randomised controlled trial in Iran further validated these findings, showing significant reductions in psychological distress among women who received the intervention compared to those receiving routine care (19). Although proven effective the stakeholders and consumers felt adaption was necessary to suit the context. The ‘ADAPT’ process developed by Moore and colleagues (2021) (20) (see Box 1) provided a systematic approach to adapting and transferring the intervention to a new context. Input to the adaptation process was facilitated through three co-design focus groups attended by consumers and midwives, who also had the opportunity to email feedback to the study lead. This approach allowed for intervention co-design drawing on collective professional expertise and lived experience. Box 1 Steps to Moore and colleagues’ ADAPT method (2021) The goal was to draw from Gamble’s original tool and identify key conversational elements that both groups agreed would help women constructively reflect on their birth experiences. The final intervention included five key conversation prompts (see Box 2) that align with the tone and content of typical postnatal birth review discussions, ensuring that the midwife-led debriefing process feels supportive, familiar to all, and a natural inclusion in routine care. Box 2. Five prompts for the birth debrief Participant recruitment Participant group one – postnatal women Purposive sampling was used to recruit participants who met the study inclusion criteria. All eligible women (n= 624) who utilised the study site’s Visiting Midwifery Service postnatal home visits were offered the intervention between January and July 2025. Opt-out recruitment design was chosen as it has been found that up to 60% of publicly funded clinical trials do not reach their target sample size (21) and this is one method to help ensure a higher level of recruitment. The birth debriefing process was explained to potential participants by a visiting midwife, who also asked if they would like to join a study for which a survey would be emailed a few weeks later capturing their experiences of the intervention. Halfway through the study period the recruitment plan was revised to add a research midwife to the team to approach potential participants during pregnancy as another strategy to increase the sample size. Individuals who had experienced an adverse event related to the current birth (for example, they had experienced a fetal or early neonatal death) were excluded. Participant group two – Midwives and midwifery managers All midwives who delivered the intervention were invited to complete the post intervention survey (n= 22). These participants, along with four midwifery managers, also completed a validated instrument designed to capture health professionals’ knowledge, attitude, and practice of trauma informed care (22). Effectiveness Data collection Effectiveness data were collected using an online post-intervention survey administered via the REDCap platform (23). The survey to capture effectiveness of the intervention was adapted for the maternity setting and had been used by other authors in the field of childbirth research (24, 25) and consequently validated as a part of this project (BDeep –Birth DEbrief Effectiveness Questionnaire). A scannable QR code linked the women to the evaluation study Participant Information Letter and Consent Form; clicking on ‘I consent’ enabled them to access the survey’s questions (Appendix 1). Demographic data were also collected, including for example model of care and birth mode and self-reported mental health issues. [Please insert Box 3] Data analysis Quantitative effectiveness data were analysed using descriptive and inferential statistical tests. These tests were conducted using SPSS software and included percentage responses (proportions), ranges, and for comparative purposes, the t test (26). Rigour was ensured through piloting testing, consistency check such as Cronbach’s alpha, the large sample size, and triangulation. The qualitative effectiveness data were analysed using Interpretive Description-style thematic analysis (27) to code and categorise the qualitative data provided against the single open-ended survey question. The Standards for Reporting Implementation Studies: the StaRI checklist for completion steered the reporting guidelines for the study (28). Findings Participant group one – postnatal women The ‘effectiveness’ survey was completed by 107 participants who were predominantly aged 31-35 years (42.1%, n=45) and university educated (60.7%, n=65), with first-time mothers comprising 49.5% (n=53) of the sample (see Figure 1). The majority experienced vaginal birth (69.2%, n=74), with care models evenly distributed between continuity of midwifery care (49.5%, n=53) and non-continuity hospital-based care (43.9%, n=47). Birth trauma history was reported by 13.6% (n=14) of women participants, while mental health history was reported by 19.8% (n=21). See Figure 1. Figurative representation of select demographic data. Quantitative findings Women's Satisfaction with the Debrief Service Satisfaction with the midwife-led post birth debrief intervention was consistently high across all measured domains and across models of care. Of eleven Likert-scale questions, eight achieved median scores of 5.0 (strongly agree), with the remaining three achieving median scores of 4.0 (agree). Near-unanimous agreement was found for universal service availability, with 87% of responses at the maximum score. Most questions demonstrated good consensus with interquartile ranges of 1.0 for eight out of eleven questions. See Figure 2. Box and Whisker Plot of Likert Scale Responses Midwifery model of care - predictors of satisfaction Significant positive correlations were found between care model and satisfaction measures, with continuity of midwifery care associated with higher satisfaction ratings for sharing birth stories (Pearson r=0.285, p=0.003), desire to talk about birth (r=0.304, p=0.002), and several other debrief domains. Similarly, birth mode (vaginal birth) showed a significant positive correlation with perceived benefit of sharing birth stories (r=0.222, p=0.022). Notable intercorrelations were found between demographic variables themselves, including mental health history and birth trauma (Spearman ρ=0.218, p=0.026), and age with both mental health (ρ=0.196, p=0.043) and birth trauma histories (ρ=0.200, p=0.040), suggesting interconnected vulnerabilities in these groups. This missing correlation data had minimal impact on overall conclusions given the consistent pattern of non-significant relationships across demographic variables. While care model and birth mode showed some associations with satisfaction, individual demographic and clinical characteristics did not influence satisfaction with the debrief service, indicating the intervention's effectiveness across diverse participant backgrounds. Birth Trauma and mental health There was a statistically significant positive correlation between birth trauma and preexisting mental health diagnosis (r = 0.238, p = 0.015), with women reporting birth trauma being 4.1 times more likely to have a mental health history compared to women without birth trauma (OR= 4.125, 95% CI: 1.240-13.723). See Figure 3. Figurative correlation of Birth trauma and mental health. Younger women also reported higher rates of mental health history (ρ=-0.196, p=0.043). While no relationships between birth trauma and debrief satisfaction reached statistical significance, women with birth trauma (n=14) showed a pattern of rating cognitive and functional questions slightly lower (opportunity to ask questions ρ=-0.112, problem-solving ρ=-0.088, understanding birth ρ=-0.073, feeling emotionally stronger ρ=-0.069) while rating relationship-focused questions slightly higher (preference for same midwife to debrief ρ=+0.097, emotional wellbeing cared for ρ=+0.074), with the lack of significance likely due to small sample size rather than absence of effect. In contrast, women with mental health history (n=21) showed three statistically significant positive correlations with debrief satisfaction: understanding birth process (ρ=+0.224, p=0.036), feeling emotionally stronger (ρ=+0.213, p=0.050), feeling emotional cared for (ρ=+0.218, p=0.035), rating these experiences 0.30 to 0.47 points higher on average with a uniformly positive directional pattern across 10 of 11 questions. The significant association between mental health history and birth trauma, combined with varied satisfaction responses, suggests that midwife-led birth debrief serves dual functions as both a preventive intervention for women with mental health vulnerabilities (who are at higher trauma risk) and an acceptable support service for women who experience birth trauma, underscoring the need for trauma-informed care. Summary of Quantitative Findings Three key findings were evident in the qualitative data we collected: (1) consistently high satisfaction with birth debrief services across all measured domains, with median scores of 4.0-5.0; (2) no statistically significant relationships between demographic characteristics (age, parity) and satisfaction outcomes; with adequate statistical power to rule out clinically significant demographic effects and (3) Significant positive correlations were found between care model and satisfaction measures, with continuity midwifery care associated with higher satisfaction ratings for sharing birth stories (r=0.285, p=0.003) and desire to talk about birth (r=0.304, p=0.002). These findings support the implementation of universal birth debrief protocols regardless of maternal age or parity, as all women report similarly high levels of satisfaction with the midwife-led post birth debrief service. Qualitative findings The qualitative data collected for the ‘effectiveness’ element of the study were captured in three themes: Debriefing a birth experience with a midwife fosters clarity and validation and Women’s power, strength, and confidence now and for the future are heightened through birth debriefing with a midwife. The third theme is specific to Midwifery COC Birth debriefing with a midwife engenders emotional safety. The themes, illustrated by supporting raw data, are now explained. Theme 1: Debriefing a birth experience with a midwife fosters clarity and validation. This theme, in which participants were cared for in both MCOC and non-continuity models of care are represented, describes the key impacts of the debrief conversation between the woman and the midwife. The conversation, an active conversation between the woman and midwife helped elucidate details about the birth experience, provided understanding of actions, and enabled affirmation of their feelings about their birth experience and events within it. Most participants described the debrief conversation as valuable for filling in gaps in their understanding, for example: '‘ To understand the details of my birth story so I could remember this for years to come’ (9) and ‘… to understand and process how my birth unfolded [and] get a better understanding of how my body birthed …’ (17). Having a more in-depth knowledge of their birth ‘story’, said a number of participants, led them to develop new insights into the decisions that were made through the process. For example Participant 70 shared that debriefing, ‘ Allowed space to understand what actually happened during the birth, and why certain interventions or monitoring was required [and]… space to understand the terminology often used during the process and why certain decisions were made ’ ). When a woman’s birth had been complicated or involved unexpected outcomes, the birth debrief provided the opportunity to process the experience, as the following participant said: My birth did not go as expected and resulted in a caesarean section. Understanding and talking about what happened during labour and the birth helped me accept that it was medically necessary for the birth to be a caesarean section and that I could not have birthed my baby naturally even though I wanted to. ( 12) In some cases, the debrief had a pivotal and profound effect on participants’ wellbeing: One said, ‘ It helped me heal emotionally [and] address any trauma or anxiety [and] helped me reframe … negative experiences, fostering a positive and celebratory perspective on my birth journey (25) ; for another ‘[it] helped me process and validate my thoughts and feelings. I wouldn't have had such a positive birth experience if it wasn't for this program’ (83). Another participant explained that the debrief helped validate her feelings around a difficult birth experience: After having a traumatic birth and extended hospital stay including staying in ICU talking with a midwife was helpful for me to validate my feelings about my birth experience. It took me a while to realise how traumatic my birthing experience was and talking with a midwife helped me process everything. (80) This theme represents the Midwifery knowledge and expertise as useful in providing insight into birth experiences. Midwife support/perspective fostered clinical reassurance and insight into the birth process. One participant explained: ‘ My midwife was able to explain things that happened during my labour that I wasn't aware of.’ (11) . The midwife was able to provide insights into the experience that may have been overlooked, one participants shared: ‘ Birth can be a blur. By looking back on it from the perspective of your midwife who was there for the birth can help you to gain clarity’ (83). And another participant also shared the midwifery understandings as important for the process : ‘It feels good to have someone who listen and understand what we've been through’ (6). Theme 2: Women’s power, strength, and confidence now and for the future are heightened through birth debriefing with a midwife Participants’ perceptions of how the debriefing process brought about empowerment, strength and growth in confidence, not only for the birth just experienced but for those to come in future, are captured in this Theme. Many of the participants provided similar comments to Participants 19 ‘It was an empowering discussion’, and participant 28 ‘It made me feel empowered. It helped me understand what was happening at certain times during the labour and birthing process’ and participant 52 described ‘It was great to reflect and talk about my experience - I found it empowering’). Similar to others, Participant 59 said, ‘the midwives made me feel loved, safe and comfortable ’ (59), and it was evident in the data that this helped participants process and understand their birth. Another who had MCOC explained: The debrief with our midwife was, in my opinion, absolutely essential and pivotal in my recovery mentally and physically. The care for my wellbeing throughout the pregnancy and the debriefing made me feel so much more confident … as a first-time mum. I can't explain how beneficial it was for me (61). In terms of the value of debriefing for subsequent pregnancies, participants described it as impactful. As Participant 3 put it, ‘…understanding my birth while the experience was still fresh in my mind was helpful as I understand what happened & why, and the implications (or lack of) for potential future births.’ (3) , another said it ‘allowed opportunities for me to ask questions so I can be better informed for any more pregnancies’ (20) , and according to Participant 25, it helped her ‘ heal emotionally, address any trauma or anxiety, and feel empowered and informed for future births.’ The women reported the birth experience as being a significant life event. Through the birth debrief discussion, many women described they were able to process their experience and move forward into motherhood (matrescence). ‘Although hundreds of women give birth, it is such a big event and life moment for mum. It’s good to have someone who understands your journey throughout pregnancy into motherhood to vent all your thoughts and feelings to, who isn't going to have biased opinions.’ (99). And another describing birth as a significant life event : As someone who felt reasonably positive about my birth, I think this was still a great opportunity to discuss and process such a huge life event.’ (19). Theme 3: Birth debriefing with a known midwife engenders emotional safety. In this theme we report data that adds to the already very robust body of evidence about the value of midwifery continuity of care (MCOC) from known midwives through pregnancy, birth and the postnatal period. Many of the participants in our study who received MCOC and were debriefed by one of their MCOC midwives commented about the value that having this prior knowledge of each other added to the debrief. Participants who did not receive MCOC made no mention of relationship with the debriefing midwife and so are not represented in this theme. Essentially, the therapeutic relationship engendered by MCOC reportedly fostered a deeper sense of emotional safety in participants, and they reached a greater level of emotional validation, during birth debrief than would have been possible with a stranger. With regard to emotional validation, one participant explained it thus: ‘ By talking through my birth experience with my [known] midwife I got to make sense of moments I did not understand at the time. I [also] got to re-experience the joy from the joyous moments’ (46). Another described the importance of MCOC for enabling their openness and honesty in the debriefing conversation : ‘…by having that continuity of care from 16 weeks onwards it allowed me to be honest, open and comfortable [during the debrief] to discuss anything’ (7). Many women shared the benefit of the individualised care in the MCOC arrangement as important to feeling that personalised debrief was occurring, as Participant 57 illustrates: ‘…[it] provided understanding of my personal experience. I was able to ask questions and feel well supported by the midwife. it was beneficial having the same midwife throughout my entire journey’ (57). The fact that a therapeutic relationship between the woman and the midwife had already been formed prior to debriefing meant there was an existing foundation of trust and honesty for it. It was this foundation that enabled participants to freely express her recollections of her birth and its impact with the midwife. One participant described it thus: [My midwife] was aware of [my] medical history, birth plan and expectations [before the debrief], so [being] able to discuss [my birth] outcomes with her was … meaningful and personalised... The birth was intense and emotional and did not go to plan [and] debriefing with [my midwife] meant I was able to express my feelings about the birth with someone who understood the context deeply; she was able to validate and reassure my emotions, [which] helped reduce [my] anxiety and guilt with how it unfolded, and I felt incredibly supported by her ( 50) Emotional safety was identified as being necessary for the birth debrief to be safely achieved. Most participants described this sense of safety as being engendered through their relationship with midwives, and like others, Participant 101 shared how the bond she felt with ‘her’ midwife helped her: ‘I enjoyed the bond I had with my midwife who was also present for the birth. Debriefing and having access to midwife strongly helped me in the first few days of having a new baby.’ (101). Implementation feasibility In the second half of the project, following the assessment of effectiveness, the feasibility of the intervention was evaluated. This phase focused on capturing practical considerations related to implementation, including uptake, acceptability, and the ability to integrate the intervention into routine practice. Participant group 2 - Midwifery participant demographics Fifty per cent of the eligible midwifery workforce participated in the study. Of the ten respondents, five were under 35 years of age with less than ten years of clinical experience, while five were aged over 40 years and had more than ten years of professional experience. Qualitative results - Midwives' perceptions of implementation, feasibility and acceptability The effectiveness of the intervention reported by participant women was complemented by strong professional endorsement from midwives, who unanimously supported (100%, n=10) both the appropriateness of the midwifery role in birth debriefing and their professional competence to deliver the service. For example, one midwife explained; ‘I think midwives have a unique view on birth and can often provide a more compassionate and empathetic breakdown of perhaps what happened through our labour and birth.’ (P7) and another ‘We can understand birth itself as a natural process and Our role is to be "with woman", advocate and come from a place of genuine empathy and support. We have access to the multi-disciplinary team to refer women who need extra support or clarification’ (P10). In relation to the standardised guide, more senior midwives had mixed feelings about using the guide as they felt they intuitively followed these steps. More junior midwives welcomed the guide. One participant explained; ‘If there was a particularly bad outcome that took place, the guide was useful in the sense that I could refer back to it to prompt me with alternative discussion pathways to broach the topic. ’ ‘I do believe a midwife has the perfect combination of medical knowledge but is able to deliver it in a way which can be received well by the woman.’ P 5. And another ‘As I work in a CoC model, most of the debriefs that took place for my clients were seamless and I didn't require the guide to help aid the debrief discussion as the discussion flowed easily as the events unfolded.’ Quantitative results - Trauma informed care underpins a birth debrief. The midwives were also asked to respond to a validated survey ‘Professional’s Knowledge, Attitude, and Practice about trauma informed care’ (22) as critical underpinning to safely conducting the debrief conversations. Midwives demonstrated high levels of agreement across all trauma-informed care domains, including trauma awareness and understanding, recovery-oriented principles, professional competence and collaboration, and practice implementation behaviours, indicating strong foundational knowledge for delivering trauma-sensitive debrief services. In trauma awareness and understanding, mean scores ranged from 4.00-4.80 (on a 5-point Likert scale), with particularly strong recognition that trauma affects physical, emotional, and mental wellbeing (M=4.80, SD=0.42) and that re-traumatisation can occur unintentionally (M=4.60, SD=0.52). Recovery-oriented principles were also strongly endorsed, with 90% (n=9) strongly agreeing that healing paths differ for each individual (M=4.90, SD=0.32), and 70% (n=7) strongly agreeing that informed choice is essential in trauma prevention and recovery (M=4.70, SD=0.48). See Figure 4 Likert scale response distribution. Clinical practice implementation behaviours showed the highest ratings, with mean scores of 4.70-4.90, indicating strong trauma-sensitive practice patterns. Notably, 90% (n=9) strongly agreed they offer patients choices and respect their decisions (M=4.90, SD=0.32) and tailor interactions to individual needs (M=4.90, SD=0.32). However, a significant knowledge-practice gap emerged. While 70% (n=7) strongly supported trauma-informed practice principles (M=4.70, SD=0.48), only 10% (n=1) reported comprehensive understanding of TIP, with 30% (n=3) disagreeing and 40% (n=4) remaining neutral (M=3.10, SD=0.99). Additionally, collaboration regarding TIP use showed moderate engagement (M=3.70, SD=0.67), with 40% (n=4) reporting neutral levels of knowledge-sharing with colleagues. Barrier to implementation - Resource allocation Resource allocation emerged as the primary implementation barrier, with 90% (n=9) of midwives indicating they need more time allocated for women's socioemotional mental health care. This reflects significant workload pressures that may limit capacity for comprehensive birth debriefing despite positive attitudes toward the practice. Training needs among midwives revealed an equal split, with 50% (n=5) requesting additional education in birth debriefing processes while 50% (n=5) felt adequately prepared. Regarding trauma-informed care specifically, 90% (n=9) expressed desire for more training (M=4.40, SD=0.70), with 50% (n=5) strongly agreeing they would like further education. No significant correlations were found between midwife demographics and TIP training desire (p > 0.05). Early-career midwives (2-5 years) showed the highest enthusiasm (100%, n=2), while mid-career midwives (6-10 years) displayed more variability. Overall, 90% (n=9) wanted additional TIP training regardless of age or experience. This high training demand, combined with the identified gap in comprehensive TIP understanding (M=3.10, SD=0.99), suggests that targeted professional development could improve midwives' confidence and competence in trauma-sensitive birth debriefing. Participant group 3 - Sustainability of the midwife-led debrief intervention. Three managers completed the short version of Program Sustainability Assessment Tool (PSAT) (29) to assess an intervention predicated sustainability. The survey addresses health service ability to sustain an intervention across seven domains which includes communication, strategic planning, program evaluation, partnerships, organisation capacity, environment support, funding stability. The health service scored highly demonstrating capacity to sustain the program, and areas for focus include the funding stability required to allocate extra time for debriefs as required and ensuring continued training for staff. Discussion In this study we evaluated the effectiveness and implementation feasibility of midwife-led birth debriefing and a structured guide for these post-birth conversations midwives have with women in one tertiary maternity care setting. Previously, birth debriefing has been reported as having neutral or negative effects ( 9 , 30 ), however all of participant women in this current study perceived the debrief positively. The midwife-led birth debrief is demonstrated in our data as an important mechanism through which women can explore the liminal ‘between two worlds’ nature of pregnancy and childbirth. Pregnancy and childbirth represent profound transitional phases, marked by significant physical, emotional, and identity shifts. These shifts have been conceptualised as as ‘matrescence’, ( 31 ) framing the experience as a developmental passage encompassing bio-psycho-social-political-spiritual domains that collectively shape the journey into motherhood. A more recently introduced term ‘parturescence’ ( 32 ) captures childbirth itself as a transformative rite of passage that transcends its clinical framing to profoundly reshape a woman’s identity, emotional landscape, and sense of self, either through empowerment or disempowerment, all of which was evident in our participant women’s data. These frameworks also underscore the need to provide care that supports women’s psychological transformation during the perinatal period ( 33 ). Midwives’ role in supporting the ‘mother becoming’ is imperative for the healthy transition to new parenthood, and processing the birth experience is critical to that health transition ( 34 ). However, psychosocial care is often unseen, under-recognised and under-measured. Much midwifery work is described as ‘hidden’ work ( 35 ) in terms of a construct in which midwifery work utilises many interpersonal or social skills when caring relationally and holistically for women but is not obvious and therefore not formalised in roles. Midwifery work that is not measurable is often not valued or resourced. This is a problem for the profession and those who use it: a recent large-scale international study involving 860 midwives reported a perceived lack of professional recognition from broader society and insufficient respect from other healthcare professions, and these factors were identified as contributing to the erosion of the midwifery role and scope of practice ( 36 ). Together with our findings, this work underscores the imperative to reclaim midwives’ role and scope and emancipate hidden midwifery activity such as that which supports psychosocial wellbeing visible. Finally, embedding real‑time implementation within the study design directly facilitated organisational change: as managers observed the debrief being delivered in practice, they recognised the value of this previously unseen midwifery work, which in turn strengthened their support for the intervention and led to tangible commitments to allocate time and provide training for its ongoing delivery. As previously reported by Wisdom and colleagues ( 37 ), adoption of innovation is dependent in part on “…involvement of influential potential users in the planning, research, and development of the innovation”, however we found that it is also imperative to involve those who will be sanctioning innovation uptake and sustainment as well. Implications This study demonstrates that midwife‑led birth debriefing, supported by a structured conversational guide, is both effective and feasible to implement within a tertiary maternity care setting, with important implications for policy, practice, and future research. Embedding real‑time implementation within the research design facilitated organisational awareness, critical to the scalability and sustainability of the intervention, as the intervention moved debriefing from an individual practice to an embedded service model. Future research should explore implementation of this model across diverse maternity settings to assess transferability. Limitations We acknowledge that assessing the effectiveness of the intervention with a measure that is not specific to midwife-led birth debriefing, of which there are none currently, is a potential limitation, however a recently published midwife-led birth debriefing concept analysis (2025) established a clear definition of the phenomenon and provides the basis for such a measure. The study is also limited by its single-site design and relatively short implementation period. Future research should explore the long-term impact of the intervention, its adaptability across diverse maternity settings, and its potential to reduce the incidence of birth trauma at a population level. Conclusions These findings provide important information that counters the existing narrative about the value of midwife-led debrief, and will be of interest to midwives, midwife educators, maternity care policy makers, and users of maternity services. Further research to confirm its effectiveness and implementation feasibility is indicated. Declarations Ethics approval and consent to participate: Approval to conduct the project was obtained from [redacted for peer review] Hospital and [redacted for peer review] University Human Research Ethics Committees. Consent for publication: Ethics approval included participants consent to publish results Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests : The authors declare that they have no competing interests Funding: The first author received grant funding from the Women’s and Infants’ Research Foundation ref: G1007454 . The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript Authors' contributions using CRediT statement Buchanan Kate: Conceptualization, Project management, Investigation, Data curation, Analysis, Validation, Writing- Original draft preparation . Phoebe Backhouse: Investigation, Data curation, Analysis, Validation, Writing- reviewing and editing . Leanne Graham: Methodology, Analysis, Validation, Writing-Reviewing and Editing . Amy Meagher: Methodology, Analysis, Validation, Writing-Reviewing and Editing. Sara Bayes: Methodology, Analysis, Validation, Writing- Reviewing and Editing. References Australian institute of health and Welfare. Perinatal mental health prevalence https://www.aihw.gov.au/reports/mothers-babies/data-opportunities-in-perinatal-mental-health-scre/contents/key-information-gaps Alabri Al-abri K, Edge D, Armitage CJ. Prevalence and correlates of perinatal depression. Soc Psychiatry Psychiatr Epidemiol. 2023;58(11):1581–90. Perinatal wellbeing centre. (2019). The cost of perinatal mental health in Australia. https://www.perinatalwellbeingcentre.org.au/Handlers/Download.ashx?IDMF=53aab8d3-c748-4818-abab-32a58d3c510f Birth Trauma Association. Psychological Birth trauma. https://birthtrauma.org.au/psychological-birth-trauma/ Märthesheimer S, Hagenbeck C, Helbig M, Balan P, Fehm T, Schaal NK. A longitudinal study of the subjective birth experience and the relationship to mental health . BMC Pregnancy and Childbirth [Internet]. 2025;25:1–17. Available from: http://dx.doi.org/10.1186/s12884-025-07348-y Cibralic S, Pickup W, Diaz AM, Kohlhoff J, Karlov L, Stylianakis A et al. The impact of midwifery continuity of care on maternal mental health: A narrative systematic review . Midwifery [Internet]. 2023;116. Available from: http://dx.doi.org/10.1016/j.midw.2022.103546 Stoodley C, McKellar L, Ziaian T, Steen M, Fereday J, Gwilt I. The role of midwives in supporting the development of the mother-infant relationship: a scoping review . BMC psychology [Internet]. 2023;11(1):71. Available from: http://dx.doi.org/10.1186/s40359-023-01092-8 Wojcieszek AM, Bonet M, Portela A, Althabe F, Bahl R, Chowdhary N, Dua T, Edmond K, Gupta S, Rogers LM, Souza JP, Oladapo OT. WHO recommendations on maternal and newborn care for a positive postnatal experience: strengthening the maternal and newborn care continuum. BMJ Glob Health. 2023;8(Suppl 2):e010992. 10.1136/bmjgh-2022-010992 . PMID: 36717156; PMCID: PMC9887708. Small R, Lumley J, Donohue L, Potter A, Waldenström U. Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth . BMJ: British Medical Journal. 2000;321(7268):1043–7. Sigurðardóttir VL, Gamble J, Guðmundsdóttir B, Sveinsdóttir H, Gottfreðsdóttir H. Processing birth experiences: A content analysis of women’s preferences. Midwifery [Internet]. 2019;69:29–38. Available from: http://dx.doi.org/10.1016/j.midw.2018.10.016 Buendicho A-L, Allen K. Perceptions of birth and wellbeing after birth debriefing among women who describe their birth as traumatic. Midwifery [Internet]. 2025;141:104267. Available from: http://dx.doi.org/10.1016/j.midw.2024.104267 Hammoda A-O, et al. Identifying barriers and facilitators of translating research evidence into clinical practice: A systematic review of reviews. Health Soc Care Commun. 2022;30(6):e3265–76. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation Hybrid Designs: Combining Elements of Clinical Effectiveness and Implementation Research to Enhance Public Health Impac t. Med Care. 2012;50(3):217. Landes SJ, et al. An Introduction to Effectiveness-Implementation Hybrid Designs. Psychiatry Res [Ireland]. 2019;280(112513). https://doi.org/10.1016/j.psychres.2019.112513 . Creswell JW, Creswell JD. Research desing: qualitative, quantitative and mixed methods approaches. United State of America: Sage; 2014. Barwick M. Checklist to Assess Organizational Readiness (CARI) for EIP Implementation. Toronto, ON: Hospital for Sick Children Toronto; 2011. Gamble J, Creedy DK. A counselling model for postpartum women after distressing birth experiences. Midwifery [Internet]. 2009;25(2):e21–30. Available from: http://dx.doi.org/10.1016/j.midw.2007.04.004 Creedy D, Gamble J, Jarrett V. The effect of midwife-led counselling on mental health outcomes for women experiencing a traumatic childbirth: a RCT. Aust NZ J Psychiatry. 2011;45:A39. Sajedi SS, Navvabi-Rigi S-D, Navidian A. Midwifery-led brief counseling on the severity of posttraumatic stress symptoms of postpartum hemorrhage: quasi-experimental study. BMC Pregnancy and Childbirth [Internet]. 2024;24:1–10. Available from: http://dx.doi.org/10.1186/s12884-024-06923-z Moore G, Campbell M, Copeland L, Craig P, Movsisyan A, Hoddinott P et al. Adapting interventions to new contexts-the ADAPT guidance. BMJ: British Medical Journal (Online) [Internet]. 2021;374. Available from: http://dx.doi.org/10.1136/bmj.n16791 Hagström J, Woodford J, von Essen A, Lähteenmäki P, von Essen L. Opt-out rates and reasons for non-participation in a single-arm feasibility trial (ENGAGE) of a guided internet-administered CBT-based intervention for parents of children treated for cancer: a nested cross-sectional survey. BMJ Open [Internet]. 2022;12(4). Available from: http://dx.doi.org/10.1136/bmjopen-2021-056758 King S, Chen K-LD, Chokshi B. Becoming Trauma Informed: Validating a Tool to Assess Health Professional’s Knowledge, Attitude, and Practice. Pediatric Quality & Safety [Internet]. 2019;4(5). Available from: http://dx.doi.org/10.1097/pq9.0000000000000215 Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L et al. The REDCap consortium: Building an international community of software platform partners. Journal of biomedical informatics [Internet]. 2019;95:103208. Available from: http://dx.doi.org/10.1016/j.jbi.2019.103208 Selkirk R, McLaren S, Ollerenshaw A, McLachlan AJ, Moten J. The longitudinal effects of midwife-led postnatal debriefing on the psychological health of mothers. Journal of Reproductive and Infant Psychology [Internet]. 2006;24(2):133–47. Available from: http://dx.doi.org/10.1080/02646830600643916 Baxter J. Postnatal debriefing: women’s need to talk after birth. British Journal of Midwifery [Internet]. 2019;27(9):563–71. Available from: http://dx.doi.org/10.12968/bjom.2019.27.9.563 Ross A, Willson VL. Basic and advanced statistical tests: Writing results sections and creating tables and figures. Volume 3. Springer; 2018 Jan. Wilson J. Interpretive description and reflexive thematic analysis: Exploring conceptual coherence and methodological integrity. Qual Health Res. 2025 Oct;8:10497323251378303. Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ et al. Standards for Reporting Implementation Studies (StaRI) Statement. BMJ: British Medical Journal (Online) [Internet]. 2017;356:i6795. Available from: http://dx.doi.org/10.1136/bmj.i6795 Calhoun A, Mainor A, Moreland-Russell S, Maier RC, Brossart L, Luke DA. Using the Program Sustainability Assessment Tool to Assess and Plan for Sustainability. Prev Chronic Dis. 2014;11:130185. http://dx.doi.org/10.5888/pcd11 . 130185External Web Site Icon. Bastos MH, Furuta M, Small R, McKenzie-McHarg K, Bick D. Debriefing interventions for the prevention of psychological trauma in women following childbirth. The Cochrane Database of Systematic Reviews [Internet]. 2015;2015(4). Available from: http://dx.doi.org/10.1002/14651858.CD007194.pub2 Athan AM. A critical need for the concept of matrescence in perinatal psychiatry. Frontiers in psychiatry [Internet]. 2024;15:1364845. Available from: http://dx.doi.org/10.3389/fpsyt.2024.1364845 Kurz E. Parturescence: a post qualitative inquiry into women’s opportunities for transcendence and transformation through birth. Journal and proceedings of the Royal Society of New South Wales [Internet]. 2022;155(1):116. Available from: http://dx.doi.org/10.5962/p.389590 Buchanan K, Geraghty S, Whitehead L, Newnham E. Woman-centred ethics: A feminist participatory action research. Midwifery [Internet]. 2023;117. Available from: http://dx.doi.org/10.1016/j.midw.2022.103577 Buchanan K, O’Reilly E, Wilcox G, Bayes S, Kearney L, Sweet L et al. Midwife-led birth debrief: A concept analysis. Midwifery [Internet]. 2025;151:104647. Available from: http://dx.doi.org/10.1016/j.midw.2025.104647 Buchanan K, Dawson K, Taylor J, Bayes S. The work of midwives: The socio-institutional theory of the meaning of midwives’ work-life balance. Midwifery [Internet]. 2025;140. Available from: http://dx.doi.org/10.1016/j.midw.2024.104240 Pezaro S, Zarbiv G, Jones J, Lilei Feika M, Fitzgerald L, Lukele S et al. Exploring Midwives’ and Nurse-Midwives’ Professional Identity and How Midwifery May Be Best Represented in the Public Realm: A Global Convergent Parallel Mixed‐Methods Study. Journal of Advanced Nursing [Internet]. 2025;81(6):3283–95. Available from: http://dx.doi.org/10.1111/jan.16696 Wisdom JP, Chor KHB, Hoagwood KE, Horwitz SM, Innovation Adoption. A Review of Theories and Constructs. Administration and Policy in Mental Health and Mental Health Services Research [Internet]. 2014;41(4):480–502. Available from: http://dx.doi.org/10.1007/s10488-013-0486-4 Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx Cite Share Download PDF Status: Published Journal Publication published 16 Apr, 2026 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 03 Feb, 2026 Editor assigned by journal 29 Jan, 2026 Submission checks completed at journal 29 Jan, 2026 First submitted to journal 27 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8707221","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":584764581,"identity":"43fd1334-bc67-4865-bff0-f347c1c8c7a4","order_by":0,"name":"Kate 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2","display":"","copyAsset":false,"role":"figure","size":103755,"visible":true,"origin":"","legend":"\u003cp\u003eBox and Whisker Plot of Likert Scale Responses\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8707221/v1/4d499f141f10c3f36c5df97c.png"},{"id":101833635,"identity":"50e0c78a-b161-4788-ae16-62e7ba2bec42","added_by":"auto","created_at":"2026-02-04 07:05:35","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":60404,"visible":true,"origin":"","legend":"\u003cp\u003eFigurative correlation of Birth trauma and mental health\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8707221/v1/9e4efbf724f1ebebaf6e5035.png"},{"id":101881782,"identity":"a9ebddf7-f432-455d-8033-4f4e264202d1","added_by":"auto","created_at":"2026-02-04 15:16:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":112863,"visible":true,"origin":"","legend":"\u003cp\u003eLikert scale response distribution\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8707221/v1/52d33addbbb1dd783c0e7dcd.png"},{"id":107351040,"identity":"8c32071b-496d-4203-8a26-51057e229358","added_by":"auto","created_at":"2026-04-20 16:08:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":951556,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8707221/v1/236413ac-c6c8-41c6-a865-15d76efdcd24.pdf"},{"id":101833636,"identity":"dc70c787-fc63-48e1-beb7-130e37e17ce2","added_by":"auto","created_at":"2026-02-04 07:05:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22882,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8707221/v1/62be76b16176d1d9b352a6fc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Co-design and feasibility testing of a midwife-led birth debrief: An implementation science project","fulltext":[{"header":"Background","content":"\u003cp\u003eThe period spanning pregnancy, birth and postpartum is characterised by psychosocial as well as physiological changes. These changes are not always positive though: many women experience new or worsening mental ill-health during the perinatal period. There is currently a significant gap in the way information about perinatal mental health is collected in Australia, and therefore the Australian Institute of Health and Welfare (1), which collates and published all national perinatal data and related information, is unable to report on perinatal mental illness rates, screening practices, service utilisation, or outcomes. According to other organisations, 1 in 5 childbearing women experience anxiety and 1 in 7 experience depression (2,\u0026nbsp;3).\u0026nbsp;Additionally, up to 30% of the perinatal population are thought to experience birth trauma (4). While the causes of diminished perinatal mental health are multifactorial, the birth experience itself is a recognised contributing factor (see for example 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the postpartum period, midwives play a vital role in supporting new mother’s psychosocial adjustments, (6) mother infant relationships (7) and a particular role in promoting mental health through education and screening\u0026nbsp;(8).\u0026nbsp;One aspect of the midwifery role is holding a conversation with a person about their birth experience, often called a birth debrief (BD). A decade ago, a Cochrane review (9) found no definitive evidence to support or reject psychological debriefing in relation to childbirth; consequently, midwife-led debrief was largely discontinued. Many smaller studies since, however, have demonstrated its promise (10) but despite this, midwife-led birth debriefing is still not commonly offered: in a recent study only 26% of women reported receiving a debrief from a midwife after giving birth, and 64.4% were unaware of what it is and what it entails, even though 80% expressed a desire for such conversations\u0026nbsp;(11). \u0026nbsp;This underutilisation and lack of awareness highlight a critical shortfall in postnatal emotional support services; it is also representative of the challenges health services face in translating and implementing evidence into care in a timely manner (12). Demonstrating the effectiveness of standardised midwifery-initiated birth debriefing is essential to ensure consistent, evidence-based support that helps women process their birth experiences, reduces psychological distress, and promotes positive maternal well-being, and exploring its implementability is important to identify barriers to its sustained uptake.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of our study was to assess the effectiveness and feasibility of midwife-led birth debriefing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eTo implement a midwife-led birth debriefing intervention in an Australian maternity service.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTo report the perceived effect of the midwife-led birth debriefing intervention from women’s perspective.\u003c/li\u003e\n \u003cli\u003eTo report the implementability of the midwife-led birth debriefing intervention.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e Approval to conduct the project was obtained from [redacted for peer review] Hospital and [redacted for peer review] University Human Research Ethics Committees.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was set at an Australian tertiary maternity service that supports 3 600 births per year to women cared for in a range of models including medically led, midwife-led and blended options.\u0026nbsp;\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eContext Analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA focus group (FG) comprising midwives, managers and consumers was convened to guide the study. The FG\u0026rsquo;s first tasks were to conduct a needs assessment and a context analysis to gauge readiness of the practice environment for change. Once it was determined through conversation that there was an appetite for capturing the midwifery role in post-birth debriefing, the \u0026lsquo;Checklist to Assess Readiness for Implementation\u0026rsquo; (\u0026lsquo;CARI\u0026rsquo; [16]) was used to guide the assessment of the study site\u0026rsquo;s change readiness. The CARI is a widely used framework to guide assessment of contextual determinants of implementation (16) and the purpose of having a range of stakeholders complete it for this project was to elicit barriers to and drivers for the adoption of the proposed innovative in the index practice setting from different viewpoints.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention and instrument development using ADAPT methods\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe basis for our intervention was a pre-existing validated and structured process called the \u0026lsquo;Traumatic Childbirth Counselling Intervention\u0026rsquo;, which was developed by Gamble and colleagues in (17). This original intervention was a midwife-led, brief telephone counselling approach that demonstrated its effectiveness in reducing PTSD, depression, and anxiety (18,17). A recent randomised controlled trial in Iran further validated these findings, showing significant reductions in psychological distress among women who received the intervention compared to those receiving routine care (19). Although proven effective the stakeholders and consumers felt adaption was necessary to suit the context. The \u0026lsquo;ADAPT\u0026rsquo; process developed by Moore and colleagues (2021) (20) (see Box 1) provided a systematic approach to adapting and transferring the intervention to a new context. Input to the adaptation process was facilitated through three co-design focus groups attended by consumers and midwives, who also had the opportunity to email feedback to the study lead. This approach allowed for intervention co-design drawing on collective professional expertise and lived experience.\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eBox 1 Steps to Moore and colleagues\u0026rsquo; ADAPT method (2021)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe goal was to draw from Gamble\u0026rsquo;s original tool and identify key conversational elements that both groups agreed would help women constructively reflect on their birth experiences. The final intervention included five key conversation prompts (see Box 2) that align with the tone and content of typical postnatal birth review discussions, ensuring that the midwife-led debriefing process feels supportive, familiar to all, and a natural inclusion in routine care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBox 2. Five prompts for the birth debrief\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cimg 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\"\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant recruitment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipant group one \u0026ndash; postnatal women\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling was used to recruit participants who met the study inclusion criteria. All eligible women (n= 624) who utilised the study site\u0026rsquo;s Visiting Midwifery Service postnatal home visits were offered the intervention\u0026nbsp;between\u0026nbsp;January and July 2025. Opt-out recruitment design was chosen as it has been found that up to 60% of publicly funded clinical trials do not reach their target sample size (21) and this is one method to help ensure a higher level of recruitment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe birth debriefing process was explained to potential participants by a visiting midwife, who also asked if they would like to join a study for which a survey would be emailed a few weeks later capturing their experiences of the intervention. Halfway through the study period the recruitment plan was revised to add a research midwife to the team to approach potential participants during pregnancy as another strategy to increase the sample size.\u0026nbsp;Individuals who had experienced an adverse event related to the current birth (for example, they had experienced a fetal or early neonatal death) were excluded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipant group two \u0026ndash; Midwives and midwifery managers\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll midwives who delivered the intervention were invited to complete the post intervention survey (n= 22). These participants, along with four midwifery managers, also completed a validated instrument designed to capture health professionals\u0026rsquo; knowledge, attitude, and practice\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eof trauma informed care (22). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEffectiveness\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEffectiveness data were collected using an online post-intervention survey administered via the REDCap platform (23). \u0026nbsp;The survey to capture effectiveness of the intervention was adapted for the maternity setting and had been used by other authors in the field of childbirth research (24, 25) and consequently validated as a part of this project (BDeep \u0026ndash;Birth DEbrief Effectiveness Questionnaire). A scannable QR code linked the women to the evaluation study Participant Information Letter and Consent Form; clicking on \u0026lsquo;I consent\u0026rsquo; enabled them to access the survey\u0026rsquo;s questions (Appendix 1). Demographic data were also collected, including for example model of care and birth mode and self-reported mental health issues.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Please insert Box 3]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative effectiveness data were analysed using descriptive and inferential statistical tests. These tests were conducted using SPSS software and included percentage responses (proportions), ranges, and for comparative purposes, the t test (26). Rigour was ensured through piloting testing, consistency check such as Cronbach\u0026rsquo;s alpha, the large sample size, and triangulation. The qualitative effectiveness data were analysed using Interpretive Description-style thematic analysis (27) to code and categorise the qualitative data provided against the single open-ended survey question. The Standards for Reporting Implementation Studies: the StaRI checklist for completion steered the reporting guidelines for the study (28).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipant group one \u0026ndash; postnatal women\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe \u0026lsquo;effectiveness\u0026rsquo; survey was completed by 107 participants who were predominantly aged 31-35 years (42.1%, n=45) and university educated (60.7%, n=65), with first-time mothers comprising 49.5% (n=53) of the sample (see Figure 1). The majority experienced vaginal birth (69.2%, n=74), with care models evenly distributed between continuity of midwifery care (49.5%, n=53) and non-continuity hospital-based care (43.9%, n=47). Birth trauma history was reported by 13.6% (n=14) of women participants, while mental health history was reported by 19.8% (n=21). See Figure 1. Figurative representation of select demographic data. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative findings\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWomen\u0026apos;s Satisfaction with the Debrief Service\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSatisfaction with the midwife-led post birth debrief intervention was consistently high across all measured domains and across models of care. Of eleven Likert-scale questions, eight achieved median scores of 5.0 (strongly agree), with the remaining three achieving median scores of 4.0 (agree). Near-unanimous agreement was found for universal service availability, with 87% of responses at the maximum score. Most questions demonstrated good consensus with interquartile ranges of 1.0 for eight out of eleven questions. See Figure 2. Box and Whisker Plot of Likert Scale Responses\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMidwifery model of care - predictors of satisfaction\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSignificant positive correlations were found between care model and satisfaction measures, with continuity of midwifery care associated with higher satisfaction ratings for sharing birth stories (Pearson r=0.285, p=0.003), desire to talk about birth (r=0.304, p=0.002), and several other debrief domains. Similarly, birth mode (vaginal birth) showed a significant positive correlation with perceived benefit of sharing birth stories (r=0.222, p=0.022). Notable intercorrelations were found between demographic variables themselves, including mental health history and birth trauma (Spearman \u0026rho;=0.218, p=0.026), and age with both mental health (\u0026rho;=0.196, p=0.043) and birth trauma histories (\u0026rho;=0.200, p=0.040), suggesting interconnected vulnerabilities in these groups. This missing correlation data had minimal impact on overall conclusions given the consistent pattern of non-significant relationships across demographic variables. While care model and birth mode showed some associations with satisfaction, individual demographic and clinical characteristics did not influence satisfaction with the debrief service, indicating the intervention\u0026apos;s effectiveness across diverse participant backgrounds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBirth Trauma and mental health\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was a statistically significant positive correlation between birth trauma and preexisting mental health diagnosis (r = 0.238, p = 0.015), with women reporting birth trauma being 4.1 times more likely to have a mental health history compared to women without birth trauma (OR= 4.125, 95% CI: 1.240-13.723). See Figure 3. Figurative correlation of Birth trauma and mental health. \u0026nbsp;Younger women also reported higher rates of mental health history (\u0026rho;=-0.196, p=0.043). While no relationships between birth trauma and debrief satisfaction reached statistical significance, women with birth trauma (n=14) showed a pattern of rating cognitive and functional questions slightly lower (opportunity to ask questions \u0026rho;=-0.112, problem-solving \u0026rho;=-0.088, understanding birth \u0026rho;=-0.073, feeling emotionally stronger \u0026rho;=-0.069) while rating relationship-focused questions slightly higher (preference for same midwife to debrief \u0026rho;=+0.097, emotional wellbeing cared for \u0026rho;=+0.074), with the lack of significance likely due to small sample size rather than absence of effect. In contrast, women with mental health history (n=21) showed three statistically significant positive correlations with debrief satisfaction: understanding birth process (\u0026rho;=+0.224, p=0.036), feeling emotionally stronger (\u0026rho;=+0.213, p=0.050), feeling emotional cared for (\u0026rho;=+0.218, p=0.035), rating these experiences 0.30 to 0.47 points higher on average with a uniformly positive directional pattern across 10 of 11 questions. The significant association between mental health history and birth trauma, combined with varied satisfaction responses, suggests that midwife-led birth debrief serves dual functions as both a preventive intervention for women with mental health vulnerabilities (who are at higher trauma risk) and an acceptable support service for women who experience birth trauma, underscoring the need for trauma-informed care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSummary of Quantitative Findings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree key findings were evident in the qualitative data we collected: (1) consistently high satisfaction with birth debrief services across all measured domains, with median scores of 4.0-5.0; (2) no statistically significant relationships between demographic characteristics (age, parity) and satisfaction outcomes; with adequate statistical power to rule out clinically significant demographic effects and (3) Significant positive correlations were found between care model and satisfaction measures, with continuity midwifery care associated with higher satisfaction ratings for sharing birth stories (r=0.285, p=0.003) and desire to talk about birth (r=0.304, p=0.002). These findings support the implementation of universal birth debrief protocols regardless of maternal age or parity, as all women report similarly high levels of satisfaction with the midwife-led post birth debrief service.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQualitative findings\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative data collected for the \u0026lsquo;effectiveness\u0026rsquo; element of the study were captured in three themes: \u003cem\u003eDebriefing a birth experience with a midwife fosters clarity and validation\u0026nbsp;\u003c/em\u003eand \u003cem\u003eWomen\u0026rsquo;s power, strength, and confidence now and for the future are heightened through birth debriefing with a midwife.\u003c/em\u003e The third theme is specific to Midwifery COC \u003cem\u003eBirth debriefing with a midwife engenders emotional safety.\u0026nbsp;\u003c/em\u003e The themes, illustrated by supporting raw data, are now explained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 1: Debriefing a birth experience with a midwife fosters clarity and validation.\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis theme, in which participants were cared for in both MCOC and non-continuity models of care are represented, describes the key impacts of the debrief conversation between the woman and the midwife. The conversation, an active conversation between the woman and midwife helped elucidate details about the birth experience, provided understanding of actions, and enabled affirmation of their feelings about their birth experience and events within it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost participants described the debrief conversation as valuable for filling in gaps in their understanding, for example: \u0026apos;\u0026lsquo;\u003cem\u003eTo understand the details of my birth story so I could remember this for years to come\u0026rsquo; (9)\u0026nbsp;\u003c/em\u003eand \u0026lsquo;\u0026hellip; \u003cem\u003eto understand and process how my birth unfolded [and] get a better understanding of how my body birthed \u0026hellip;\u0026rsquo; (17).\u0026nbsp;\u003c/em\u003eHaving a more in-depth knowledge of their birth \u0026lsquo;story\u0026rsquo;, said a number of participants, led them to develop new insights into the decisions that were made through the process. For example Participant 70 shared that debriefing, \u0026lsquo;\u003cem\u003eAllowed space to understand what actually happened during the birth, and why certain interventions or monitoring was required [and]\u0026hellip; space to understand the terminology often used during the process and why certain decisions were made\u003c/em\u003e\u0026rsquo;\u003cem\u003e).\u003c/em\u003e When a woman\u0026rsquo;s birth had been complicated or involved unexpected outcomes, the birth debrief provided the opportunity to process the experience, as the following participant said:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMy birth did not go as expected and resulted in a caesarean section. Understanding and talking about what happened during labour and the birth helped me accept that it was medically necessary for the birth to be a caesarean section and that I could not have birthed my baby naturally even though I wanted to.\u003c/em\u003e (\u003cem\u003e12)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn some cases, the debrief had a pivotal and profound effect on participants\u0026rsquo; wellbeing: One said, \u0026lsquo;\u003cem\u003eIt helped me heal emotionally [and] address any trauma or anxiety [and] helped me reframe \u0026hellip; negative experiences, fostering a positive and celebratory perspective on my birth journey (25)\u003c/em\u003e; for another \u003cem\u003e\u0026lsquo;[it] helped me process and validate my thoughts and feelings. I wouldn\u0026apos;t have had such a positive birth experience if it wasn\u0026apos;t for this program\u0026rsquo; (83).\u0026nbsp;\u003c/em\u003eAnother participant explained that the debrief helped validate her feelings around a difficult birth experience: \u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAfter having a traumatic birth and extended hospital stay including staying in ICU talking with a midwife was helpful for me to validate my feelings about my birth experience. It took me a while to realise how traumatic my birthing experience was and talking with a midwife helped me process everything. (80)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis theme represents the Midwifery knowledge and expertise as useful in providing insight into birth experiences. Midwife support/perspective fostered clinical reassurance and insight into the birth process. One participant explained: \u0026lsquo;\u003cem\u003eMy midwife was able to explain things that happened during my labour that I wasn\u0026apos;t aware of.\u0026rsquo; (11) .\u0026nbsp;\u003c/em\u003eThe midwife was able to provide insights into the experience that may have been overlooked, one participants shared: \u0026lsquo;\u003cem\u003eBirth can be a blur. By looking back on it from the perspective of your midwife who was there for the birth can help you to gain clarity\u0026rsquo; (83).\u0026nbsp;\u003c/em\u003eAnd another participant also shared the midwifery understandings as important for the process\u003cem\u003e: \u0026lsquo;It feels good to have someone who listen and understand what we\u0026apos;ve been through\u0026rsquo; (6).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2: Women\u0026rsquo;s power, strength, and confidence now and for the future are heightened through birth debriefing with a midwife\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants\u0026rsquo; perceptions of how the debriefing process brought about empowerment, strength and growth in confidence, not only for the birth just experienced but for those to come in future, are captured in this Theme. Many of the participants provided similar comments to Participants 19 \u003cem\u003e\u0026lsquo;It was an empowering discussion\u0026rsquo;, and participant\u0026nbsp;\u003c/em\u003e28 \u003cem\u003e\u0026lsquo;It made me feel empowered. It helped me understand what was happening at certain times during the labour and birthing process\u0026rsquo; and participant 52\u003c/em\u003e described \u003cem\u003e\u0026lsquo;It was great to reflect and talk about my experience - I found it empowering\u0026rsquo;).\u0026nbsp;\u003c/em\u003eSimilar to others, Participant 59 said, \u003cem\u003e\u0026lsquo;the midwives made me feel loved, safe and comfortable\u003c/em\u003e\u0026rsquo; (59), and it was evident in the data that this helped participants process and understand their birth.\u003c/p\u003e\n\u003cp\u003eAnother who had MCOC explained:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe debrief with our midwife was, in my opinion, absolutely essential and pivotal in my recovery mentally and physically. The care for my wellbeing throughout the pregnancy and the debriefing made me feel so much more confident \u0026hellip; as a first-time mum. I can\u0026apos;t explain how beneficial it was for me (61).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In terms of the value of debriefing for subsequent pregnancies, participants described it as impactful. As Participant 3 put it, \u003cem\u003e\u0026lsquo;\u0026hellip;understanding my birth while the experience was still fresh in my mind was helpful as I understand what happened \u0026amp; why, and the implications (or lack of) for potential future births.\u0026rsquo; (3)\u003c/em\u003e, another said it \u003cem\u003e\u0026lsquo;allowed opportunities for me to ask questions so I can be better informed for any more pregnancies\u0026rsquo; (20)\u003c/em\u003e, and according to Participant 25, it helped her \u0026lsquo;\u003cem\u003eheal emotionally, address any trauma or anxiety, and feel empowered and informed for future births.\u0026rsquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe women reported the birth experience as being a significant life event. \u0026nbsp;Through the birth debrief discussion, many women described they were able to process their experience and move forward into motherhood (matrescence).\u003cem\u003e\u0026nbsp;\u0026lsquo;Although hundreds of women give birth, it is such a big event and life moment for mum. It\u0026rsquo;s good to have someone who understands your journey throughout pregnancy into motherhood to vent all your thoughts and feelings to, who isn\u0026apos;t going to have biased opinions.\u0026rsquo; (99).\u0026nbsp;\u003c/em\u003eAnd another describing birth as a significant life event\u003cem\u003e: As someone who felt reasonably positive about my birth, I think this was still a great opportunity to discuss and process such a huge life event.\u0026rsquo; (19).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 3: Birth debriefing with a known midwife engenders emotional safety.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this theme we report data that adds to the already very robust body of evidence about the value of midwifery continuity of care (MCOC) from known midwives through pregnancy, birth and the postnatal period. Many of the participants in our study who received MCOC and were debriefed by one of their MCOC midwives commented about the value that having this prior knowledge of each other added to the debrief. Participants who did not receive MCOC made no mention of relationship with the debriefing midwife and so are not represented in this theme. Essentially, the therapeutic relationship engendered by MCOC reportedly fostered a deeper sense of emotional safety in participants, and they reached a greater level of emotional validation, during birth debrief than would have been possible with a stranger. With regard to emotional validation, one participant explained it thus: \u0026lsquo;\u003cem\u003eBy talking through my birth experience with my [known] midwife I got to make sense of moments I did not understand at the time. I [also] got to re-experience the joy from the joyous moments\u0026rsquo; (46).\u003c/em\u003e Another described the importance of MCOC for enabling their openness and honesty in the debriefing conversation\u003cem\u003e: \u0026lsquo;\u0026hellip;by having that continuity of care from 16 weeks onwards it allowed me to be honest, open and comfortable [during the debrief] to discuss anything\u0026rsquo; (7).\u003c/em\u003e Many women shared the benefit of the individualised care in the MCOC arrangement as important to feeling that personalised debrief was occurring, as Participant 57 illustrates:\u003cem\u003e\u0026nbsp;\u0026lsquo;\u0026hellip;[it] provided understanding of my personal experience. \u0026nbsp;I was able to ask questions and feel well supported by the midwife. it was beneficial having the same midwife throughout my entire journey\u0026rsquo; (57).\u003c/em\u003e The fact that a therapeutic relationship between the woman and the midwife had already been formed prior to debriefing meant there was an existing foundation of trust and honesty for it. It was this foundation that enabled participants to freely express her recollections of her birth and its impact with the midwife. One participant described it thus:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e[My midwife] was aware of [my] medical history, birth plan and expectations [before the debrief], so [being] able to discuss [my birth] outcomes with her was \u0026hellip; meaningful and personalised... The birth was intense and emotional and did not go to plan [and] debriefing with [my midwife] meant I was able to express my feelings about the birth with someone who understood the context deeply; she was able to validate and reassure my emotions, [which] helped reduce [my] anxiety and guilt with how it unfolded, and I felt incredibly supported by her\u003c/em\u003e (\u003cem\u003e50)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEmotional safety was identified as being necessary for the birth debrief to be safely achieved. Most participants described this sense of safety as being engendered through their relationship with midwives, and like others, Participant 101 shared how the bond she felt with \u0026lsquo;her\u0026rsquo; midwife helped her: \u003cem\u003e\u0026lsquo;I enjoyed the bond I had with my midwife who was also present for the birth. Debriefing and having access to midwife strongly helped me in the first few days of having a new baby.\u0026rsquo; (101).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation feasibility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the second half of the project, following the assessment of effectiveness, the feasibility of the intervention was evaluated. This phase focused on capturing practical considerations related to implementation, including uptake, acceptability, and the ability to integrate the intervention into routine practice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipant group 2 - Midwifery participant demographics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFifty per cent of the eligible midwifery workforce participated in the study. Of the ten respondents, five were under 35 years of age with less than ten years of clinical experience, while five were aged over 40 years and had more than ten years of professional experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative results - Midwives\u0026apos; perceptions of implementation, feasibility and acceptability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe effectiveness of the intervention reported by participant women was complemented by strong professional endorsement from midwives, who unanimously supported (100%, n=10) both the appropriateness of the midwifery role in birth debriefing and their professional competence to deliver the service.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor example, one midwife explained; \u003cem\u003e\u0026lsquo;I think midwives have a unique view on birth and can often provide a more compassionate and empathetic breakdown of perhaps what happened through our labour and birth.\u0026rsquo; (P7)\u0026nbsp;\u003c/em\u003eand another\u003cem\u003e\u0026nbsp;\u0026lsquo;We can understand birth itself as a natural process and Our role is to be \u0026quot;with woman\u0026quot;, advocate and come from a place of genuine empathy and support. We have access to the multi-disciplinary team to refer women who need extra support or clarification\u0026rsquo; (P10).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn relation to the standardised guide, more senior midwives had mixed feelings about using the guide as they felt they intuitively followed these steps. \u0026nbsp;More junior midwives welcomed the guide. One participant explained;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;If there was a particularly bad outcome that took place, the guide was useful in the sense that I could refer back to it to prompt me with alternative discussion pathways to broach the topic.\u003c/em\u003e\u0026rsquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I do believe a midwife has the perfect combination of medical knowledge but is able to deliver it in a way which can be received well by the woman.\u0026rsquo; P 5.\u0026nbsp;\u003c/em\u003eAnd another\u003cem\u003e\u0026nbsp;\u0026lsquo;As I work in a CoC model, most of the debriefs that took place for my clients were seamless and I didn\u0026apos;t require the guide to help aid the debrief discussion as the discussion flowed easily as the events unfolded.\u0026rsquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQuantitative results - Trauma informed care underpins a birth debrief.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe midwives were also asked to respond to a validated survey \u0026lsquo;Professional\u0026rsquo;s Knowledge, Attitude, and Practice about trauma informed care\u0026rsquo; (22) as critical underpinning to safely conducting the debrief conversations. Midwives demonstrated high levels of agreement across all trauma-informed care domains, including trauma awareness and understanding, recovery-oriented principles, professional competence and collaboration, and practice implementation behaviours, indicating strong foundational knowledge for delivering trauma-sensitive debrief services. In trauma awareness and understanding, mean scores ranged from 4.00-4.80 (on a 5-point Likert scale), with particularly strong recognition that trauma affects physical, emotional, and mental wellbeing (M=4.80, SD=0.42) and that re-traumatisation can occur unintentionally (M=4.60, SD=0.52). Recovery-oriented principles were also strongly endorsed, with 90% (n=9) strongly agreeing that healing paths differ for each individual (M=4.90, SD=0.32), and 70% (n=7) strongly agreeing that informed choice is essential in trauma prevention and recovery (M=4.70, SD=0.48). See Figure 4 Likert scale response distribution.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical practice implementation behaviours showed the highest ratings, with mean scores of 4.70-4.90, indicating strong trauma-sensitive practice patterns. Notably, 90% (n=9) strongly agreed they offer patients choices and respect their decisions (M=4.90, SD=0.32) and tailor interactions to individual needs (M=4.90, SD=0.32).\u003c/p\u003e\n\u003cp\u003eHowever, a significant knowledge-practice gap emerged. While 70% (n=7) strongly supported trauma-informed practice principles (M=4.70, SD=0.48), only 10% (n=1) reported comprehensive understanding of TIP, with 30% (n=3) disagreeing and 40% (n=4) remaining neutral (M=3.10, SD=0.99). Additionally, collaboration regarding TIP use showed moderate engagement (M=3.70, SD=0.67), with 40% (n=4) reporting neutral levels of knowledge-sharing with colleagues.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarrier to implementation - Resource allocation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResource allocation emerged as the primary implementation barrier, with 90% (n=9) of midwives indicating they need more time allocated for women\u0026apos;s socioemotional mental health care. This reflects significant workload pressures that may limit capacity for comprehensive birth debriefing despite positive attitudes toward the practice.\u003c/p\u003e\n\u003cp\u003eTraining needs among midwives revealed an equal split, with 50% (n=5) requesting additional education in birth debriefing processes while 50% (n=5) felt adequately prepared. Regarding trauma-informed care specifically, 90% (n=9) expressed desire for more training (M=4.40, SD=0.70), with 50% (n=5) strongly agreeing they would like further education. No significant correlations were found between midwife demographics and TIP training desire (p \u0026gt; 0.05). Early-career midwives (2-5 years) showed the highest enthusiasm (100%, n=2), while mid-career midwives (6-10 years) displayed more variability. Overall, 90% (n=9) wanted additional TIP training regardless of age or experience. This high training demand, combined with the identified gap in comprehensive TIP understanding (M=3.10, SD=0.99), suggests that targeted professional development could improve midwives\u0026apos; confidence and competence in trauma-sensitive birth debriefing.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipant group 3 - Sustainability of the midwife-led debrief intervention.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThree managers completed the short version of Program Sustainability Assessment Tool (PSAT) (29) to assess an intervention predicated sustainability. The survey addresses health service ability to sustain an intervention across seven domains which includes communication, strategic planning, program evaluation, partnerships, organisation capacity, environment support, funding stability. The health service scored highly demonstrating capacity to sustain the program, and areas for focus include the funding stability required to allocate extra time for debriefs as required and ensuring continued training for staff. \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study we evaluated the effectiveness and implementation feasibility of midwife-led birth debriefing and a structured guide for these post-birth conversations midwives have with women in one tertiary maternity care setting. Previously, birth debriefing has been reported as having neutral or negative effects (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), however all of participant women in this current study perceived the debrief positively. The midwife-led birth debrief is demonstrated in our data as an important mechanism through which women can explore the liminal \u0026lsquo;between two worlds\u0026rsquo; nature of pregnancy and childbirth.\u003c/p\u003e \u003cp\u003ePregnancy and childbirth represent profound transitional phases, marked by significant physical, emotional, and identity shifts. These shifts have been conceptualised as as \u0026lsquo;matrescence\u0026rsquo;, (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) framing the experience as a developmental passage encompassing bio-psycho-social-political-spiritual domains that collectively shape the journey into motherhood. A more recently introduced term \u0026lsquo;parturescence\u0026rsquo; (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) captures childbirth itself as a transformative rite of passage that transcends its clinical framing to profoundly reshape a woman\u0026rsquo;s identity, emotional landscape, and sense of self, either through empowerment or disempowerment, all of which was evident in our participant women\u0026rsquo;s data. These frameworks also underscore the need to provide care that supports women\u0026rsquo;s psychological transformation during the perinatal period (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Midwives\u0026rsquo; role in supporting the \u0026lsquo;mother becoming\u0026rsquo; is imperative for the healthy transition to new parenthood, and processing the birth experience is critical to that health transition (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, psychosocial care is often unseen, under-recognised and under-measured. Much midwifery work is described as \u0026lsquo;hidden\u0026rsquo; work (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) in terms of a construct in which midwifery work utilises many interpersonal or social skills when caring relationally and holistically for women but is not obvious and therefore not formalised in roles. Midwifery work that is not measurable is often not valued or resourced. This is a problem for the profession and those who use it: a recent large-scale international study involving 860 midwives reported a perceived lack of professional recognition from broader society and insufficient respect from other healthcare professions, and these factors were identified as contributing to the erosion of the midwifery role and scope of practice (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Together with our findings, this work underscores the imperative to reclaim midwives\u0026rsquo; role and scope and emancipate hidden midwifery activity such as that which supports psychosocial wellbeing visible.\u003c/p\u003e \u003cp\u003eFinally, embedding real‑time implementation within the study design directly facilitated organisational change: as managers observed the debrief being delivered in practice, they recognised the value of this previously unseen midwifery work, which in turn strengthened their support for the intervention and led to tangible commitments to allocate time and provide training for its ongoing delivery. As previously reported by Wisdom and colleagues (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), adoption of innovation is dependent in part on \u0026ldquo;\u0026hellip;involvement of influential potential users in the planning, research, and development of the innovation\u0026rdquo;, however we found that it is also imperative to involve those who will be sanctioning innovation uptake and sustainment as well.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eThis study demonstrates that midwife‑led birth debriefing, supported by a structured conversational guide, is both effective and feasible to implement within a tertiary maternity care setting, with important implications for policy, practice, and future research. Embedding real‑time implementation within the research design facilitated organisational awareness, critical to the scalability and sustainability of the intervention, as the intervention moved debriefing from an individual practice to an embedded service model. Future research should explore implementation of this model across diverse maternity settings to assess transferability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWe acknowledge that assessing the effectiveness of the intervention with a measure that is not specific to midwife-led birth debriefing, of which there are none currently, is a potential limitation, however a recently published midwife-led birth debriefing concept analysis (2025) established a clear definition of the phenomenon and provides the basis for such a measure. The study is also limited by its single-site design and relatively short implementation period. Future research should explore the long-term impact of the intervention, its adaptability across diverse maternity settings, and its potential to reduce the incidence of birth trauma at a population level.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThese findings provide important information that counters the existing narrative about the value of midwife-led debrief, and will be of interest to midwives, midwife educators, maternity care policy makers, and users of maternity services. Further research to confirm its effectiveness and implementation feasibility is indicated.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eApproval to conduct the project was obtained from [redacted for peer review] Hospital and [redacted for peer review] University Human Research Ethics Committees.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eEthics approval included participants consent to publish results\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003e The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe first author received grant funding from the Women’s and Infants’ Research Foundation\u003cstrong\u003e\u0026nbsp;ref: G1007454\u003c/strong\u003e. The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions using CRediT statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBuchanan Kate:\u003c/strong\u003e Conceptualization, Project management, Investigation, Data curation, Analysis, Validation, Writing- Original draft preparation\u003cstrong\u003e. Phoebe Backhouse:\u0026nbsp;\u003c/strong\u003eInvestigation, Data curation, Analysis, Validation, Writing- reviewing and editing\u003cstrong\u003e. Leanne Graham:\u0026nbsp;\u003c/strong\u003eMethodology, Analysis, Validation, Writing-Reviewing and Editing\u003cstrong\u003e. Amy Meagher:\u0026nbsp; \u0026nbsp;\u003c/strong\u003eMethodology, Analysis, Validation, Writing-Reviewing and Editing.\u003cstrong\u003e\u0026nbsp;Sara Bayes:\u003c/strong\u003e Methodology, Analysis, Validation, Writing- Reviewing and Editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAustralian institute of health and Welfare. Perinatal mental health prevalence \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aihw.gov.au/reports/mothers-babies/data-opportunities-in-perinatal-mental-health-scre/contents/key-information-gaps\u003c/span\u003e\u003cspan address=\"https://www.aihw.gov.au/reports/mothers-babies/data-opportunities-in-perinatal-mental-health-scre/contents/key-information-gaps\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlabri Al-abri K, Edge D, Armitage CJ. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1007/s10488-013-0486-4\u003c/span\u003e\u003cspan address=\"10.1007/s10488-013-0486-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Perinatal mental health, perinatal counselling, birth debriefing, midwifery ","lastPublishedDoi":"10.21203/rs.3.rs-8707221/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8707221/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The period spanning pregnancy, birth and postpartum is characterised by psychosocial as well as physiological changes: many women experience new or worsening mental ill-health during the perinatal period. Midwives play a critical role in supporting and promoting psycho-social health by providing mental health education, counselling and screening. Often this includes a post-birth conversation, guided reflection, or debrief. Information about the effectiveness and experiences of specific and structured midwife-led birth debrief is scant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e The aim of our study was to assess the perceived effectiveness, experiences and implementability of postnatal midwife-led birth debriefing intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A Type II hybrid effectiveness – implementation design, specifically convergent mixed methods combining quantitative descriptive statistics with qualitative thematic analysis, was employed to simultaneously evaluate the clinical impact of a birth debriefing guide and its implementation within one Australian tertiary maternity service. ‘Effectiveness’ participants included women who had given birth in the nine months prior to study commencement, and ‘implementation’ participants included midwives and managers. Data were collected between January and September 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations \u003c/strong\u003eApproval to conduct the study was obtained from two Human Research Ethics Committees.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The ‘effectiveness’ sample comprised 105 postnatal women. Satisfaction with the midwife-led post birth debrief intervention was consistently high across all measured domains and across models of care. A history of mental illness (n=21) was positively and statistically significantly correlated with three debrief satisfaction components: understanding birth process (ρ=+0.224, p=0.036), feeling emotionally stronger (ρ=+0.213, p=0.050), and feeling emotionally cared for (ρ=+0.218, p=0.035). Three themes were derived from qualitative data to describe the positive and powerful impact of midwife-led birth debrief on women. In terms of implementability, midwives unanimously endorsed the standardised birth debrief as a valuable tool and emphasised the need for trauma-informed care as its foundation, and sustainability assessments by managers scored highly, confirming the feasibility of translating midwife-led birth debriefing into routine practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: This study highlights the significance of midwife-led birth debriefing in supporting women’s perinatal mental health during the liminal perinatal period and underscores its potential to inform maternity care practice, policy and impact.\u003c/p\u003e","manuscriptTitle":"Co-design and feasibility testing of a midwife-led birth debrief: An implementation science project","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-04 07:05:30","doi":"10.21203/rs.3.rs-8707221/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-03T05:17:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-30T04:10:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-30T04:09:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-27T07:24:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"262a7287-30f4-4283-8fff-68f5fc746f4d","owner":[],"postedDate":"February 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:06:07+00:00","versionOfRecord":{"articleIdentity":"rs-8707221","link":"https://doi.org/10.1186/s12889-026-27342-z","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-04-16 15:58:12","publishedOnDateReadable":"April 16th, 2026"},"versionCreatedAt":"2026-02-04 07:05:30","video":"","vorDoi":"10.1186/s12889-026-27342-z","vorDoiUrl":"https://doi.org/10.1186/s12889-026-27342-z","workflowStages":[]},"version":"v1","identity":"rs-8707221","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8707221","identity":"rs-8707221","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}