Fine tuning fear of childbirth: the relationship between Childbirth Fear Questionnaire subscales and demographic and reproductive variables

The effect of interventions in vaginal birth on fear of childbirth: A multicentre study

AIM

This cross-sectional multicentre study aimed to determine the effect of interventions during vaginal birth for fear of childbirth.

METHODS

In this cross-sectional and analytical study, 852 women who had a vaginal birth between 2019 and 2020 were enrolled. Data were collected using the Descriptive Questionnaire and Wijma Birth Expectation/Experience Scale Version B.

RESULTS

The mean total Wijma Birth Expectation/Experience Scale Version B score of the women was 97.00 ± 24.24, indicating severe and clinical levels of fear of childbirth. Moreover, 69.4% of the women had clinical, 18.6% had severe and 12% had moderate levels of fear of childbirth. During birth, women who had close supporters, who were allowed to move and who did not undergo amniotomy, enema, perineal shaving and electronic foetal monitoring had a low level of fear of childbirth. As the number of pregnant women in the labour room, frequency of vaginal examinations, duration of delivery/hour, severity of labour pain and negative perception of the approach of health professionals increased, the women's fear of childbirth increased. Fear of childbirth decreased as the frequency of antenatal follow-ups, number of births and satisfaction levels of the women increased (p < 0.05). Low income perception, irregular prenatal follow-up, severe labour pain and a long duration of labour were strong predictors of increased fear of childbirth. Increasing number of births, high birth satisfaction level and positive perception of the approach of health professionals were strong predictors of reduced fear of childbirth.

CONCLUSIONS

The reduction of interventions in vaginal delivery and support from health care providers during delivery can be effective in reducing fear of childbirth.

The relationship of childhood maltreatment, adult sexual victimization, depressed mood and symptoms of trauma with fear of childbirth

BACKGROUND

Fear of childbirth (FoB) is experienced to some degree by most pregnant people and can be intense enough to merit treatment. Despite significant research on the topic of FoB, studies investigating various forms of maltreatment and mental health symptoms in relation to FoB are very limited. In particular, studies including multiple forms of maltreatment along with mental health symptoms as predictors of FoB are extremely limited. We sought to fill this gap and clarify the relative contributions of these variables to the prediction of FoB.

METHODS

This was a secondary analysis of data from pregnant people in Canada. Participants (N = 881) provided demographic and reproductive history information, completed self-report measures of FoB, childhood maltreatment (multiple forms), adult sexual victimization, depressed mood and symptoms of posttraumatic stress disorder (PTSD). They were also administered a diagnostic interview to assess for specific phobia, FoB. Analyses included descriptive information, Wilcoxon rank sum tests, linear and logistic regression, and path analysis.

RESULTS

Most forms of maltreatment showed some association with increased FoB. However, when assessed together, only emotional maltreatment remained a significant predictor of FoB. Both depressed mood and symptoms of PTSD contributed more to FoB than maltreatment, and mediated the relationship of emotional maltreatment with FoB. The only direct effects of childhood emotional maltreatment on FoB were for fears of medical interventions and feelings of embarrassment during labour and delivery.

LIMITATIONS

Study findings fill significant gaps in our understanding of the relationship between maltreatment, mental health symptoms and FoB. However, the study sample was limited to Canadian participants, most of whom were socio-economically advantaged, cis-gender women of European descent, thus limiting the generalizability of the findings. Further, as childhood maltreatment and sexual assault experiences in adulthood were reported retrospectively, study findings are also vulnerable to recall bias.

CONCLUSIONS

Findings contribute to our understanding of the relationship between childhood maltreatment, adult sexual victimization, mental health and FoB. These findings can facilitate future research and improved care via a focus on depressed mood, symptoms of PTSD, emotional maltreatment and specific fears of medical interventions and social discomfort as significant contributors to one's experience of FoB.

Comparison of State-Trait Anxiety and Fear of Childbirth According to Attachment Styles of Pregnant Women

AIMS/BACKGROUND

Fear of childbirth (FoC) and its extreme form, tokophobia, is a clinical condition that can lead to many negative consequences, and its importance is increasingly understood. This article aims to assess the severity of FoC and anxiety levels according to different attachment styles and to investigate the relationships between these factors.

DESIGN/METHODS

A cross-sectional study was conducted in a state hospital in the largest city in Turkey. Three hundred pregnant women attending the Antenatal Outpatient Clinic were included. A sociodemographic questionnaire, Wijma Delivery Expectancy/Experience Questionnaire-version-A (W-DEQ), Spielberger State-Trait Anxiety Inventory and Adult Attachment Style Scale were administered.

RESULTS

8.1% of participants had tokophobia (W-DEQ sum score ≥85). FoC was significantly higher in pregnant women who had a history of pregnancy loss and past psychiatric history. For multiparous women, adverse birth outcomes were also associated with higher FoC. State and trait anxiety were positively correlated with FoC levels. Regarding the attachment patterns, pregnant women with avoidant attachment styles presented with higher levels of FoC than those with secure attachment styles. In logistic regression analysis, higher anxiety levels, adverse birth outcomes, and insecure attachment styles were found to predict severe and clinical FoC.

CONCLUSION

FoC has a considerable effect on pregnant women, albeit at different clinical levels. Adverse birth outcomes, high anxiety levels, and insecure attachment styles were associated with higher FoC. Therefore, antenatal patients with adverse birth outcomes and higher anxiety levels, which are risk factors for FoC, should be carefully evaluated in terms of tokophobia and referred to mental health professionals when necessary.

Tocophobia: a nosological quagmire

Fear of childbirth exists on a continuum of severity, and the most severe form is commonly referred to as tocophobia. Although a rare entity, tocophobia is a common reason for requesting an elective cesarean section. It is generally considered a specific phobia but is not recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a diagnostic entity. To improve the assessment and treatment of tocophobia, research is warranted to clarify its relationship with commonly occurring psychiatric disorders in pregnancy.

Effectiveness of Psychological Interventions to Improve the Mental Well-Being of Parents Who Have Experienced Traumatic Childbirth: A Systematic Review and Meta-Analysis

Considering the adverse impact that traumatic childbirth experiences can have on parental mental well-being, studies that have investigated the potential of providing postnatal psychological support for this group of parents require evaluation. This systematic review aimed to examine the effectiveness of psychological interventions at improving the mental well-being of parents who have experienced traumatic childbirth in terms of anxiety, depression, fear of childbirth, and post-traumatic stress disorder (PTSD) symptoms. Seven electronic databases were searched from their respective inception dates up to January 2021. Only quantitative studies that reported the effects of psychological interventions on anxiety, depression, fear of childbirth, and/or PTSD symptoms in selective (at risk of traumatic childbirth experience) or indicated (self-defined childbirth experience as traumatic for any reason) populations of parents (mothers and/or fathers) were included. Eight studies were included and meta-analyses were conducted using a random-effect model. All studies were conducted on mothers only, and one study had minimal father involvement. Results showed that psychological interventions were more effective in reducing fear of childbirth and improving PTSD symptoms compared to anxiety and depression. Greater improvement in depression was reported at 3-8 weeks' follow-up than at immediate post-intervention. Subgroup analyses showed that technology-based interventions were feasible, and indicated interventions were more effective than selective interventions. Conducting future interventions in more geographical regions, engaging and including fathers more actively, incorporating both personalized professional therapy and informal peer support, striving for flexibility and convenience, as well as addressing topics on self-doubt and coping skills can improve current interventions.

Fear of Childbirth in Nulliparous Women

Purpose

The relation between fear of childbirth (FoC) and gestational age is inconclusive, and self-reported need for help regarding this fear has never been investigated. This study aimed to determine the prevalence and course of FoC according to gestational age, to identify risk factors for the development of FoC, the influence of this fear on preferred mode of delivery, and self-reported need for help.

Methods

Nulliparous pregnant women of all gestational ages completed an online survey. The study consisted of a cross-sectional and a longitudinal analysis. Women who completed the survey in the first or second trimester (T₀) were approached again in their third trimester (T₁). The Wijma Delivery Expectancy Questionnaire Version A (W-DEQ A) was used with a cut-off score ≥ 85 to define presence of fear of childbirth. Questionnaires indexing social support, anxiety, symptoms of depression, preferred mode of delivery, and self-reported need for help were included.

Results

In total, 364 women were enrolled at T₀, and 118 out of 184 eligible women were included in the longitudinal analysis. Point prevalence of FoC at T₀ was 18.4% with no significant difference between trimesters. In the longitudinal sample, the prevalence of FoC decreased from 18.6% (T₀) to 11.0% (T₁), p = 0.004. Although mean scores for FoC decreased significantly, p < 0.001, scores increased in 41 (34.7%) women. The presence of FoC was associated with elevated anxiety, less family support, prenatal care of the obstetrician by choice, preference for a cesarean section, and for pain relief. Women with FoC were more likely to actively seek for help compared to women without FoC.

Conclusion

While FoC is common in each trimester, prevalence decreases over the course of pregnancy. Women with FoC are often actively seeking for help, suggesting that this fear should be addressed better, and help should be offered accordingly.

Traumatic Childbirth Experiences of New Parents: A Meta-Synthesis

Childbirth is usually a joyous occasion. However, a significant proportion of parents experienced traumatic childbirths and suffered post-traumatic consequences, which needs urgent attention. Therefore, this review aimed to explore and understand the traumatic childbirth experiences of parents. A systematic review of qualitative studies was done. The consolidated evidence was meta-summarized and meta-synthesized based on Sandelowski and Barroso's approach for synthesizing qualitative research. Seven electronic databases, including PubMed, CINAHL, Embase, PsycINFO, Cochrane, Scopus, and Web of Science, were searched from each database's inception to April 2020. Retrieved studies were screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and 19 studies were included in this review. All included studies were meta-summarized and meta-synthesized. An overarching theme, "traumatic birth: an evolving voyage," with three main themes, (1) "proceedings to traumatic birth," (2) "internal and external battles," and (3) "muddling through to beating the odds," and 10 subthemes were identified. Overall, parents felt fluctuations of emotions that seemed to be never-ending journeys. They expressed that various factors led to their traumatic birth experiences, especially health care providers' dismissive attitudes. Parents commonly reported feelings of powerlessness and fear for the safety of mothers and infants. Their constant battles to overcome traumatic experiences affected some of their relationships. To deal with the trauma, some mothers displayed avoidance behaviors while others relied on social support. As health care providers play important roles in influencing outcomes of childbirth, they should be mindful of the care provided during labors and childbirths.

The Prevalence of Fear of Childbirth and Its Association With Intolerance of Uncertainty and Coping Styles Among Pregnant Chinese Women During the COVID-19 Pandemic

Background

Fear of childbirth (FOC) is one of the most common psychological symptoms among pregnant women and significantly relates to cesarean section, anxiety, and depression. However, it is not clear the prevalence and risk factors of FOC among Chinese pregnant women since the outbreak of the COVID-19 pandemic.

Aims

The objective of this study was to examine the associations between coping styles, intolerance of uncertainty, and FOC.

Method

From December 2021 to April 2022, a cross-sectional survey was conducted in two hospitals in China through convenient sampling. The cross-sectional survey was conducted among 969 pregnant women, which included the Childbirth Attitude Questionnaire (CAQ), Intolerance of Uncertainty Scale-12 (IUS-12), and Simplified Coping Style Questionnaire (SCSQ).

Results

The total prevalence of FOC was 67.8%. The percentages of women with mild (a score of 28-39), moderate (40-51), and severe FOC (52-64) were 43.6, 20.2, and 4.0%, respectively. The regression results indicated that primiparas, unplanned pregnancy, few spousal support, intolerance of uncertainty, and negative coping styles were significant risk factors of FOC. Women who adopt positive coping strategies experienced a lower level of childbirth fear.

Conclusion

These findings suggest that cultivating positive coping styles and obtaining sufficient childbirth information may be helpful for mothers' mental health. Regular screening assessment of perinatal psychological symptoms, such as the high level of intolerance of uncertainty and negative coping styles, should be adopted to reduce the risk of fear of childbirth.

The Childbirth Fear Questionnaire and the Wijma Delivery Expectancy Questionnaire as Screening Tools for Specific Phobia, Fear of Childbirth

Background: Perinatal anxiety and related disorders are common (20%), distressing and impairing. Fear of childbirth (FoB) is a common type of perinatal anxiety associated with negative mental health, obstetrical, childbirth and child outcomes. Screening can facilitate treatment access for those most in need. Objectives: The purpose of this research was to evaluate the accuracy of the Childbirth Fear Questionnaire (CFQ) and the Wijma Delivery Expectations Questionnaire (W-DEQ) of FoB as screening tools for a specific phobia, FoB. Methods: A total of 659 English-speaking pregnant women living in Canada and over the age of 18 were recruited for the study. Participants completed an online survey of demographic, current pregnancy and reproductive history information, as well as the CFQ and the W-DEQ, and a telephone interview to assess specific phobia FoB. Results: Symptoms meeting full and subclinical diagnostic criteria for a specific phobia, FoB, were reported by 3.3% and 7.1% of participants, respectively. The W-DEQ met or exceeded the criteria for a “good enough” screening tool across several analyses, whereas the CFQ only met these criteria in one analysis and came close in three others. Conclusions: The W-DEQ demonstrated high performance as a screening tool for a specific phobia, FoB, with accuracy superior to that of the CFQ. Additional research to ensure the stability of these findings is needed.

Validation and Psychometric Properties of the Spanish Version of the Fear of Childbirth Questionnaire (CFQ-e)

The fear of childbirth is a topical concern, yet the issue has barely been studied in Spain, and only one fear of childbirth measurement instrument has been validated in the country. The aim of this study was to translate, adapt and validate the Fear of Childbirth Questionnaire (CFQ) for use in Spain, as well as to describe and evaluate the psychometric properties of the Spanish version of this instrument. In a first phase, a methodological study was carried out (translation–backtranslation and cross-cultural adaptation), and pilot study was carried out in the target population. In addition, content validation of the instrument was obtained (CFQ-e) from 10 experts. In the second phase, a cross-sectional study was carried out at several centres in Gran Canaria Island to obtain a validation sample. The evaluation of the psychometric properties of the CFQ-e, including construct validity through exploratory factor analysis and confirmatory factor analysis, the calculation of reliability via factor consistency using the ORION coefficients as well as alpha and omega coefficients were carried out. The CFQ-e showed evidence of content validity, adequate construct validity and reliability. The CFQ-e is composed of 37 items distributed in four subscales or dimensions: “fear of medical interventions”; “fear of harm and dying”; “fear of pain” and “fears relating to sexual aspects and embarrassment”. The CFQ-e constitutes a valid and reliable tool to measure the fear of childbirth in the Spanish pregnant population.

The Fear of Childbirth and Social Support in Adolescent Pregnancy

OBJECTIVE

Social support may be effective in alleviating fear associated with childbirth in pregnant adolescent women. This study was conducted to determine the relationship between social support and fear of childbirth in adolescent pregnancy.

DESIGN

The study was designed to assess any relationships between the social support perceived by pregnant adolescent women and the fear of childbirth that they experienced. through a cross-sectional analysis.

SETTING

The study was carried out in the obstetrics outpatient clinics of a public hospital.

PATIENTS

The study was conducted with 100 pregnant adolescents.

MEASUREMENTS

A personal information form, the Multidimensional Scale for Perceived Social Support (MSPSS), and the Wijma Birth Expectancy/Experience Scale Version A (WDEQ-A) were applied for data collection. The Pearson correlation coefficient was used to determine relationships between 2 continuous variables.

RESULTS

There was a significant negative correlation between the mean scores on the MSPSS and the WDEQ-A (r = -0.345, P < .01). The MSPSS score was found to be associated with gestational age, residence area, and type of marriage. The WDEQ-A score was associated with educational status.

CONCLUSION

The results demonstrate that social support is highly important for pregnant adolescents, especially considering the fact that the social support received from the spouse was relatively lower among adolescent women with lower gestational age. Nurses should evaluate the family of the pregnant adolescent, especially their partner, in terms of the social support that they provide to the pregnant woman and should support these women with necessary counseling.

Cross-cultural Adaptation and Validation of the Childbirth Fear Prior to Pregnancy Scale in Brazil

Background:

The fear of childbirth can range from apprehension to intense fear (tokophobia), with serious consequences for maternal health. Therefore, a standardized scale is needed to measure the fear of childbirth before pregnancy.

Objective:

This study aimed to adapt the Childbirth Fear Prior to Pregnancy (CFPP) scale to the Brazilian context and analyse its validity and reliability.

Methods:

A cross-sectional survey was completed by 146 nursing students at two Brazilian universities. A committee of experts evaluated the cross-cultural adaptation of the CFPP scale. Construct validity was verified using item-total correlations and Exploratory Factor Analysis (EFA). The validity of divergent concurrent criteria was evaluated by associating the score obtained using the Brazilian CFPP with the Depression, Anxiety, and Stress Scale (DASS-21). Reliability was analysed using Cronbach’s alpha coefficient and test-retest.

Results:

Correlation analysis revealed a predominance of moderate inter-item correlation and strong item-total correlation (>0.62). The EFA indicated that all items related to a single factor, with factor loadings and communalities >0.5. These results reinforced the one-dimensionality of the Brazilian CFPP. The validity of divergent concurrent criteria was confirmed via weak correlations with DASS-21 scores (r = 0.32, p < 0.001). The Cronbach’s alpha (0.86) and the intra-class correlation coefficient (0.99) indicated reliability and strong temporal stability, respectively.

Conclusion:

The Brazilian version of the CFPP provides evidence of validity and reliability to measure fear of childbirth before pregnancy in young adults in Brazil.

Interventions to treat fear of childbirth in pregnancy: a systematic review and meta-analysis

Background

Between 5% and 14% of women suffer from fear of childbirth (FOC) which is associated with difficulties during birth and in postnatal psychological adjustment. Therefore, effective interventions are needed to improve outcomes for women. A systematic review and meta-analysis was used to identify effective interventions for treating women with FOC.

Methods

Literature searches were undertaken on online databases. Hand searches of reference lists were also carried out. Studies were included in the review if they recruited women with FOC and aimed to reduce FOC and/or improve birth outcomes. Data were synthesised qualitatively and quantitatively using meta-analysis. The literature searches provided a total of 4474 citations.

Results

After removing duplicates and screening through abstracts, titles and full texts, 66 papers from 48 studies were identified for inclusion in the review. Methodological quality was mixed with 30 out of 48 studies having a medium risk of bias. Interventions were categorised into six broad groups: cognitive behavioural therapy, other talking therapies, antenatal education, enhanced midwifery care, alternative interventions and interventions during labour. Results from the meta-analysis showed that most interventions reduced FOC, regardless of the approach (mean effect size = −1.27; z = −4.53, p < 0.0001) and that other talking therapies may reduce caesarean section rates (OR 0.48, 95% CI 0.48–0.90).

Conclusions

Poor methodological quality of studies limits conclusions that can be drawn; however, evidence suggests that most interventions investigated reduce FOC. Future high-quality randomised controlled trials are needed so that clear conclusions can be made.

Enhanced Antenatal Care: Combining one-to-one and group Antenatal Care models to increase childbirth education and address childbirth fear

BACKGROUND

We designed and implemented a new model of care, Enhanced Antenatal Care (EAC), which offers a combined approach to midwifery-led care with six one-to-one visits and four group sessions.

AIM

To assess EAC in terms of women's satisfaction with care, autonomy in decision-making, and its effectiveness in lowering childbirth fear.

METHODS

This was a quasi-experimental controlled trial comparing 32 nulliparous women who received EAC (n=32) and usual antenatal care (n=60). We compared women's satisfaction with care and autonomy in decision-making post-intervention using chi-square test. We administered a Fear of Birth Scale pre- and post-intervention and assessed change in fear of birth in each group using the Cohen's d for effect size. To isolate the effect of EAC, we then restricted this analysis to women who did not attend classes alongside maternal care (n=13 in EAC and n=13 in usual care).

FINDINGS

Women's satisfaction with care in terms of monitoring their and their baby's health was similar in both groups. Women receiving EAC were more likely than those in usual care to report having received enough information about the postpartum period (75% vs 30%) and parenting (91% vs 55%). Overall, EAC was more effective than usual care in reducing fear of birth (Cohen's d=-0.21), especially among women not attending classes alongside antenatal care (Cohen's d=-0.83).

CONCLUSION

This study is the first to report findings on EAC and suggests that this novel model may be beneficial in terms of providing education and support, as well as lowering childbirth fear.

Fear and Anxiety Disorders Related to Childbirth: Epidemiological and Therapeutic Issues

PURPOSE OF REVIEW

This paper seeks to identify the risk factors of fear of childbirth (FOC) and posttraumatic stress disorder (PTSD) related to birth and reviews the efficacy of their respective screening tools and therapeutic interventions.

RECENT FINDINGS

Biofeedback, hypnosis, internet-based cognitive behavioral therapy, and antenatal education are promising treatments for FOC. Training midwives to address traumatic birth experiences could help in preventing PTSD. A shorter more pragmatic screening tool for FOC than the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ) is needed. Women with PTSD attributed a mismatch between the expected mode of delivery (MOD) and the actual MOD as the cause of their trauma. A history of mental health disorders, lack of social support, previous negative birth experiences, and MOD are correlated to FOC and postpartum PTSD. Psycho-education and CBT-based treatments have been found to reduce levels of FOC and PTSD.