The effect of expressive writing intervention for patients with reproductive trauma on anxiety, depression and stress: a meta-analysis of randomized controlled trials

Reproductive trauma refers to traumatic experiences related to adverse reproductive events, particularly preterm birth, infertility and fetal loss. These experiences negatively impact women's physical health and often lead to long-lasting psychological burdens such as anxiety, depression, and stress. Expressive writing intervention (EWI) is a positive psychological tool characterized by its universality and portability. It has shown beneficial effects in populations with chronic illnesses. Recently, EWI has been applied to those experiencing reproductive trauma. However, the specific efficacy of EWI for patients with reproductive trauma on anxiety, depression and stress is not yet fully ascertained. The aim of this study was to assess the effectiveness of EWI as a psychological intervention for women with reproductive trauma.

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six databases, including PubMed, EMBASE, Cochrane, Web of Science, CINAHL and PsycINFO, were searched from inception to June 8, 2026 for eligible studies. Two authors independently conducted literature screening, data extraction, and quality assessment according to the inclusion and exclusion criteria. Meta-analysis was performed using Review Manager software. Prespecified subgroup analyses examined the effects of intervention duration, control conditions, and population type. Exploratory meta-regression analyses were used to assess the association between intervention dose and outcomes. And publication bias and sensitivity analyses were conducted where appropriate. We also employed TSA to assess evidence conclusiveness, and certainty of evidence was rated via GRADE.

Ten eligible studies with 838 participants were included in the final data set. Pooled analysis showed that EWI was not effective in reducing post-intervention anxiety and stress, whereas post-intervention depression showed a marginal effect (SMD = -0.35, 95% CI: -0.71 to -0.00, P = 0.05). In contrast, follow-up depression demonstrated a statistically significant effect (SMD = -0.82, 95% CI: -1.40 to -0.24, P = 0.006). Subgroup analyses showed that EWI may be effective in patients who have experienced preterm birth or fetal loss, and in studies with no-writing control conditions. Additionally, exploratory meta-regression analysis showed a potential positive association between intervention dose and improvement in follow-up stress outcomes. However, these findings should be interpreted cautiously due to the limited number of studies.

Our findings show that EWI may be beneficial in certain subgroups, such as women who have experienced fetal loss or preterm birth. However, the certainty of evidence remains limited, indicating that the current evidence is insufficient and that the effects of EWI across outcomes remains uncertain. Future studies should validate the effects of EWI through more high-quality randomized controlled trials.

The protocol was registered in the PROSPERO database with the registration ID CRD42024582557.