The Oxford Worries about Labour Scale: Women's experience and measurement characteristics of a measure of maternal concern about labour and birth

Fear of childbirth among pregnant women: A concept analysis

AIM

To clarify the concept of fear of childbirth among pregnant women and to examine its current measure tools.

BACKGROUND

Fear of childbirth is a psychological symptom, prevalent among pregnant women, which negatively impacts women's health and well-being. It has become an increasingly concerning issue in perinatal mental health. However, due to its poor conceptualization, it presents difficulty in conducting reliable assessments and identifying risk factors.

METHODS

The Walker and Avant approach to concept analysis guided this review. Six bibliographic databases were systematically searched for published research from their inception date to May 2023. Additional records were identified by manually searching the reference lists of relevant studies. Quantitative and qualitative studies investigating fear of childbirth in pregnant women were included.

RESULTS

Three critical attributes have been identified: cognitive impairments, affective disorders and somatic symptoms. Antecedents include perceived a real or anticipated threat of pregnancy or its outcomes, low perceived self-coping ability and unmet social support needs. Consequences include processing and avoiding behaviours. This study also identified the dimensions of fear of childbirth, including 6 primary categories and 14 subcategories. The content of five scales was analysed and none covered all domains.

CONCLUSIONS

The current analysis provides healthcare providers with a more comprehensive framework to assess and identify fear of childbirth. Further research is needed to develop a suitable instrument that covers all the attributes and dimensions of this concept and assesses its severity.

IMPACT

This conceptual analysis provides a comprehensive insight into the phenomenon of fear of childbirth. This will help family members, healthcare providers and policymakers to identify the psychological needs of pregnant women and improve the quality of antenatal care.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable as no new data were generated.

A new scale for fear of childbirth: the Fear of Childbirth Questionnaire (FCQ)

OBJECTIVE

To create a clear and acceptable measure of fear of childbirth with satisfactory content validity for use with English-speaking women in the UK.

BACKGROUND

Fear of childbirth (FOC) can have a significant impact on a woman's view of her pregnancy, birth and her recovery post birth. Early identification is paramount to ensure that women's needs are recognised so that appropriately tailored care can be provided in pregnancy. Availability of reliable and valid measures to assess FOC in an English-speaking population are sparse, mainly due to issues with definitions of FOC or cultural sensitivity after translation. Recent research from phase one of the Fear of Childbirth study (FOCUS), has established key elements for FOC in an English-speaking UK population, and allows for a culturally sensitive measure of FOC to be developed. The aim was to ensure inclusion of all ten FOC elements and to attend to guidance from women in phase two of the FOCUS study about what would ensure clarity and acceptability.

METHOD

A multidisciplinary team developed items in accordance with FOCUS. The measure was then piloted with one reviewer and further refined by the team of perinatal researchers.

RESULTS

The FCQ is a new 20-item fear of childbirth questionnaire, which has been developed and is grounded in fears reported by women in the UK.

CONCLUSION

A new tool to measure FOC in an English-speaking UK population with good content validity has undergone a preliminary phase of development and now needs testing for reliability and other forms of validity.

The Tokophobia Severity Scale (TSS): measurement model, power and sample size considerations

OBJECTIVE

To examine the measurement model of the Tokophobia Severity Scale and consider issues of statistical power and sample size from the original instrument development study.

BACKGROUND

Fear of childbirth (FoC) and tokophobia represents an area of increasing concern within perinatal mental health research and clinical practice. Existing measures of the FoC have been criticised due to either measurement inconsistencies, difficulties in scoring or practical clinical application. Attempting to address these limitations, researchers developed the Tokophobia Severity Scale (TSS). A fundamental assumption underpinning the use of the TSS is unidimensionality, however this assertion may have been based on sub-optimal sample size and approach taken to factor structure determination.

METHOD

Parallel analysis (PA), principal components analysis (PCA), exploratory factor analysis (EFA), power analysis and sample size calculation using a reconstruction of the original dataset from published summary data.

RESULTS

Following replication of the original PCA, a three-factor model was found to offer a significantly better fit to data than a unidimensional model. Power analysis suggested the original study was underpowered.

CONCLUSION

The TSS remains a promising tool but assumptions regarding its measurement model are based on an inadequate sample size. Sample sizes for a sufficiently powered study indicated.

Effects of online antenatal education on worries about labour, fear of childbirth, preparedness for labour and fear of covid-19 during the covid-19 pandemic: A single-blind randomised controlled study

Objective

To examine the effects of online antenatal education on worries about labour, fear of childbirth, preparedness for labour and fear of COVID-19 during the COVID-19 pandemic.

Design

A single-blind randomised controlled trial comparing two groups: an antenatal education group and a control group.

Participants

The sample consisted of 44 pregnant women.

Measurements

A demographic data form, The Oxford Worries on Labour Scale, The Fear of Birth Scale, The Prenatal Self Evaluation Questionnaire and The Fear of COVID-19 Scale were used for data collection.

Findings

Online antenatal education decreased worries about labour, fear of childbirth and fear of COVID-19 and improved preparedness for labour.

Key conclusions

Online antenatal education offered during the COVID-19 pandemic is effective in preparedness for labour.

Implications for practice

As an alternative, online antenatal education should be offered to pregnant women unable to attend face to face education programs due to fear of transmission of infection.

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.

Screening for Perinatal Anxiety Using the Childbirth Fear Questionnaire: A New Measure of Fear of Childbirth

Fear of childbirth affects as many as 20% of pregnant people, and has been associated with pregnancy termination, prolonged labour, increased risk of emergency and elective caesarean delivery, poor maternal mental health, and poor maternal-infant bonding. Currently available measures of fear of childbirth fail to fully capture pregnant people’s childbirth-related fears. The purpose of this research was to develop a new measure of fear of childbirth (the Childbirth Fear Questionnaire; CFQ) that would address the limitations of existing measures. The CFQ’s psychometric properties were evaluated through two studies. Participants for Study 1 were 643 pregnant people residing in Canada, the United States, and the United Kingdom, with a mean age of 29.0 (SD = 5.1) years, and 881 pregnant people residing in Canada, with a mean age of 32.9 (SD = 4.3) years for Study 2. In both studies, participants completed a set of questionnaires, including the CFQ, via an online survey. Exploratory factor analysis in Study 1 resulted in a 40-item, 9-factor scale, which was well supported in Study 2. Both studies provided evidence of high internal consistency and convergent and discriminant validity. Study 1 also provided evidence that the CFQ detects group differences between pregnant people across mode of delivery preference and parity. Study 2 added to findings from Study 1 by providing evidence for the dimensional structure of the construct of fear of childbirth, and measurement invariance across parity groups (i.e., the measurement model of the CFQ was generalizable across parity groups). Estimates of the psychometric properties of the CFQ across the two studies provided evidence that the CFQ is psychometrically sound, and currently the most comprehensive measure of fear of childbirth available. The CFQ covers a broad range of domains of fear of childbirth and can serve to identify specific fear domains to be targeted in treatment.

Effects of antepartum education on worries about labor and mode of delivery

AIM

This study evaluated the effects of antenatal education, which was provided in a pregnancy education class, on pregnant women's concerns about labor and the mode of delivery.

MATERIALS AND METHODS

Primigravid pregnant women (n = 144) were enrolled into the study between May 2017 and November 2018. Pregnant women received standard education on nutrition during pregnancy, exercise, methods of coping with pain, and breastfeeding. The participants completed the "Introductory Information Form" and "Oxford Worries about Labour Scale" to collect data.

RESULTS

A statistically significant difference was found between the participants' pain, distress, uncertainty, and interventions in the pre-education, post-education, and postpartum periods and mean total score on the Oxford scale (p<.05). However, education had no significant effect on the mode of delivery (p>.05).

CONCLUSION

Education provided during pregnancy significantly decreased women's worries about labor, but it did not lead to a significant difference in the modes of delivery.

Tokophobia and fear of birth: a workshop consensus statement on current issues and recommendations for future research

Objective: To discuss and develop a statement on the current state of the evidence and opinion in Fear of Childbirth (FoC) and Tokophobia (Tocophobia), and to provide recommendations. Background: A group met in 2019 to discuss the state of clinical and academic knowledge relating to FoC/Tokophobia. Five key areas were agreed as the focus of the meeting. Methods: 12 internationally acknowledged experts, in this or a closely related area (e.g. PTSD) met to discuss their understanding of the evidence for FoC/ Tokophobia and current practice. The consensus described in this paper constitutes the expression of the general opinion of the participants and does not necessarily imply unanimity. Keys points: Work focussed on tokophobia is recent and there remains a wide range of issues, which were addressed in the workshop including complexity in defining prevalence, a theoretical lack of understanding, which creates challenge for robust assessment and the identification of risk factors. An improved aetiological and developmental understanding of the tokophobia is required to underpin appropriate, effective and evidence-based interventions. Evaluation of pathways of care and relevant interventions, should be a focus of future research. Conclusion: Significant gaps remain within the FoC/tokophobia knowledge base. Further research is necessary.

Identifying fear of childbirth in a UK population: qualitative examination of the clarity and acceptability of existing measurement tools in a small UK sample

Background

Fear of childbirth is related to but not synonymous with general anxiety, and represents a superior predictor for maternal and infant outcomes. There is a need to improve the identification and provision of support for women experiencing high fear of childbirth. However it is uncertain as to whether existing measurement tools have appropriate content validity (i.e. cover the relevant domains within the construct), practical utility, and whether they are acceptable for use with a UK population. This study aimed to (1) identify the utility and acceptability of existing measures of fear of childbirth (FOC) with a small UK sample and (2) map the content of existing measures to the key concepts of fear of childbirth established by previous research.

Methods

Ten pregnant women; five with high and five with low fear of childbirth participated in a cognitive interview covering four most commonly used measures of fear of childbirth: 1. The Wijma Delivery Expectancy Questionnaire (WDEQ A), 2. The Oxford Worries about Labour Scale (OWLS), 3. The Slade-Pais Expectations of Childbirth Scale – fear subscale (SPECS) and 4. The Fear of Birth scale (FOBS). Each measure was also reviewed by participants for ease and clarity of understanding and acceptability. The measures were then reviewed against the key domains identified in the fear of childbirth literature to ascertain the adequacy of content validity of each measure. Interviews were analysed using thematic analysis for each scale item.

Results

All measures except the FOBS, included items that either women did not understand or, if where there was understanding the meanings were inconsistent across women. All measures demonstrated limited acceptability and content validity for the specific construct of FOC. Therefore, none of the measurement tools currently used within the UK met criteria for understanding, acceptability and content validity for measurement of FOC.

Conclusions

Findings emphasise a need to develop a specific fear of childbirth tool with good clarity which demonstrates appropriate content validity, and that is acceptable in presentation and length for pregnant women in a UK population.

How mothers feel: Validation of a measure of maternal mood

RATIONALE

Low mood may affect developing relationships with a new baby, partner and family. Early identification of mood disturbance is crucial to improve outcomes for women perinatally. Instruments such as the Edinburgh Postnatal Depression Scale (EPDS) are used routinely, with evidence that some women do not feel comfortable with how they are asked about their mental health.

OBJECTIVE

To develop a mood checklist as a user-friendly, effective measure of well-being in post-partum women, for use by health professionals.

METHODS

Cognitive interviews with women who had recently given birth assessed response format and face validity of a prototype measure. A cross-sectional survey followed. A random split-half instrument development protocol was used. Exploratory factor analysis determined factor structure with the first sample,. The second sample confirmed factor structure and evaluationof key psychometric variables and known-groups discriminant validity (KGDV), requiring a supplementary between-subjects design with stratification based on case negative/case positive classification using EPDSscreening cut-off criteria.

RESULTS

Cognitive interview data confirmed the face validity of the measure. Exploratory factor analysis indicated an 18 item two-factor model with two (negatively) correlated factors. Factor 1 loaded with items reflecting positive mood and factor 2 negative items. Confirmatory factor analysis showed a good fit to the two-factor model across the full spectrum of fit indices. Statistically significant differences between groups were observed in relation to as EPDS caseness classification. Cronbach alpha coefficients for the positive and negative subscales revealed acceptable internal consistency of 0.79 and 0.72, respectively.

CONCLUSION

The outcome checklist may be appropriate for use in clinical practice. It demonstrated effective psychometric properties and clear cross-validation with existing commonly used measures.

Improving the Experience of Care: Results of the American Association of Birth Centers Strong Start Client Experience of Care Registry Pilot Program, 2015-2016

In 2018, the Center for Medicare and Medicaid Innovation in the United States (US) released report demonstrating birth centers as the appropriate level of care for most Medicaid beneficiaries. A pilot project conducted at 34 American Association of Birth Centers (AABC) Strong Start sites included 553 beneficiaries between 2015 and 2016 to explore client perceptions of high impact components of care. Participants used the AABC client experience of care registry to report knowledge, values, and experiences of care. Data were linked to more than 300 process and outcome measures within the AABC Perinatal Data Registry™. Descriptive statistics, t tests, χ analysis, and analysis of variance were conducted. Participants demonstrated high engagement with care and trust in pregnancy, birth, and parenting. Beneficiaries achieved their preference for vaginal birth (89.9%) and breastfeeding at discharge through 6 weeks postpartum (91.7% and 87.6%). Beneficiaries reported having time for questions, felt listened to, spoken to in a way they understood, being involved in decision making, and treated with respect. There were no variations in experience of care, cesarean birth, or breastfeeding by race. Medicaid beneficiaries receiving prenatal care at AABC Strong Start sites demonstrated high levels of desired engagement and reported receiving respectful, accessible care and high-quality outcomes. More investment and research using client-reported data registries are warranted as the US works to improve the experience of perinatal care nationwide.

An investigation of dispositional mindfulness and mood during pregnancy

Background

Mindfulness courses are being offered to numerous groups and while a large body of research has investigated links between dispositional mindfulness and mood, few studies have reported this relationship during pregnancy. The aim of this study was to investigate this relationship in pregnant women to offer insight into whether an intervention which may plausibly increase dispositional mindfulness would be beneficial for this population.

Methods

A cross-sectional analysis was conducted to explore potential relationships between measures of mindfulness and general and pregnancy-specific mood. A sample of pregnant women (n = 363) was recruited using online advertising and community-based recruitment and asked to complete a number of questionnaires online.

Results

Overall, higher levels of mindfulness were associated with improved levels of general and pregnancy-related mood in pregnant women. Controlling for general stress and anxiety, higher scores for mindfulness in (psychologically) healthy women were associated with lower levels of pregnancy-related depression, distress and labour worry but this relationship was not apparent in those with current mental health problems. In participants without children, higher mindfulness levels were related to lower levels of pregnancy-related distress.

Conclusions

These results suggest a promising relationship between dispositional mindfulness and mood though it varies depending on background and current problems. More research is needed, but this paper represents a first step in examining the potential of mindfulness courses for pregnant women. Increasing mindfulness, and therefore completing mindfulness-based courses, is potentially beneficial for improvements in mood during pregnancy.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2416-2) contains supplementary material, which is available to authorized users.

Women's experiences of maternity care in England: preliminary development of a standard measure

BACKGROUND

As maternity services evolve and the population of women served also changes, there is a continuing need to effectively document the views of women with recent experience of care. A woman's maternity experience can have a positive or negative effect upon her emotional well-being and health, in the immediate and the long-term, which can also impact the infant and the wider family system. Measuring women's perceptions of maternity services is an important way of monitoring the quality of care provision, as well as providing key indicators to organisations of the services that they are providing. It follows that, without information identifying possible areas in need of improvement, it is not clear what changes should be made to improve the experiences of women during their journey through maternity services from pregnancy to the early weeks at home with a new baby . The objective is to describe the development process and psychometric properties of a measure of women's experience of maternity care covering the three distinctly different phases of maternity - pregnancy, labour and birth, and the early postnatal period.

METHODS

Data from a national survey of women who had recently given birth (n = 504) were used. Exploratory and confirmatory factor analytic methods were employed. The measure was assessed for underlying latent factor structure, as well as for reliability, internal consistency, and validity (predictive, convergent and discriminant).

RESULTS

The models developed confirmed the use of three separate, but related scales about experience of maternity care during pregnancy, labour and birth and the postnatal period. Data reduction was effective, resulting in a measure with 36 items (12 per scale).

CONCLUSION

The need for a psychometrically robust and qualitatively comprehensive measure of women's experience of maternity care has been addressed in the development and validation of this prototype measure. The whole measure can be used at one time point, or the three separate subscales used as individual measures of experience during particular phases of the maternity journey with identified factor structures in their own right.

Mindfulness for pregnancy: A randomised controlled study of online mindfulness during pregnancy

OBJECTIVE

Prenatal depression, stress and anxiety are significant predictors of postnatal depression and also have a direct negative impact on the family. Helpful psychological interventions during pregnancy are scarce and expensive, and usually only available for a small percentage of those suffering or deemed to be at risk. The aim of this study was to evaluate the potential of an online mindfulness course for expectant mothers.

DESIGN

A randomised study was conducted to explore differences between control and active participants allocated to take an online mindfulness course, offered free to research participants, or wait.

SETTING

The course provided was online and already available but given to study participants for free. Measures were also taken online using a secure site to collect the data.

PARTICIPANTS

185 mothers were recruited and randomised to the online course (n = 107) or a waitlist control (n = 78), with 72 completers at post-course (n = 22 active, n = 50 control) and 48 completers at postnatal follow-up (n = 16 active and n = 32 control).

INTERVENTION

The online mindfulness course is available at www.bemindfulonline.com and comprises a four-week, condensed version of an eight-week mindfulness course, with videos and written instructions for guided meditation and other mindfulness-based exercises.

MEASUREMENTS AND FINDINGS

A number of psychological well-being measurements were taken including stress, anxiety, depression and pregnancy-specific measure such as labour worry. Intention to treat analysis (baseline carried forwards) showed no group difference in stress from pre to post intervention or control.

KEY CONCLUSIONS

Results indicated that the course was potentially beneficial for those who completed it, but levels of drop out from the course were very high.

IMPLICATIONS FOR PRACTICE

Although outcomes for mothers completing the intervention were improved relative to a waitlist control, high rates of drop out indicate that the online course has low completion rates for pregnant women in its current format.

Impacts of online and group perinatal education: a mixed methods study protocol for the optimization of perinatal health services

Background

Prenatal education is a core component of perinatal care and services provided by health institutions. Whereas group prenatal education is the most common educational model, some health institutions have opted to implement online prenatal education to address accessibility issues as well as the evolving needs of future parents. Various studies have shown that prenatal education can be effective in acquisition of knowledge on labour and delivery, reducing psychological distress and maximising father’s involvement. However, these results may depend on educational material, organization, format and content. Furthermore, the effectiveness of online prenatal education compared to group prenatal education remains unclear in the literature. This project aims to evaluate the impacts of group prenatal education and online prenatal education on health determinants and users’ health status, as well as on networks of perinatal educational services maintained with community-based partners.

Methods

This multipronged mixed methods study uses a collaborative research approach to integrate and mobilize knowledge throughout the process. It consists of: 1) a prospective cohort study with quantitative data collection and qualitative interviews with future and new parents; and 2) a multiple case study integrating documentary sources and interviews with stakeholders involved in the implementation of perinatal information service networks and collaborations with community partners. Perinatal health indicators and determinants will be compared between prenatal education groups (group prenatal education and online prenatal education) and standard care without these prenatal education services (control group).

Discussion

This study will provide knowledge about the impact of online prenatal education as a new technological service delivery model compared to traditional group prenatal education. Indicators related to the complementarity of these interventions and those available in community settings will refine our understanding of regional perinatal services networks. Results will assist decision-making regarding service organization and delivery models of prenatal education services.

Protocol version

Version 1 (February 9 2018).

Care and self-reported outcomes of care experienced by women with mental health problems in pregnancy: Findings from a national survey

BACKGROUND

mental health problems in pregnancy and the postnatal period are relatively common and, in pregnancy, are associated with an increase in adverse outcome. It is recommended that all women are asked about their emotional and mental health and offered treatment if appropriate.

OBJECTIVES

to describe the care received by women self-identifying with mental health problems in pregnancy, and to describe the effects of support, advice and treatment on outcomes in the postnatal period.

DESIGN

this study used cross-sectional survey data collected in 2014 which described women's experience of maternity care.

SETTING

England PARTICIPANTS: a random sample of women who had a live birth in January 2014.

MEASUREMENTS

the questionnaire asked about sociodemographic characteristics, whether women were asked about emotional and mental health in pregnancy, support and treatment offered, about postnatal wellbeing, and questions relating to attachment to their baby. Descriptive statistics and logistic regression were used to examine the associations between mental health and outcomes taking account of sociodemographic characteristics.

FINDINGS

the survey response rate was 47%. Women with antenatal mental health problems were significantly more worried at the prospect of labour and birth, had lower satisfaction with the experience of birth, worse postnatal mental health, and indications of poorer attachment to their baby. They received substantially more care than other women but they did not always view this positively. Support, advice and treatment for mental health problems had mixed effects.

CONCLUSIONS

this study describes the significant additional care provided to women self-identifying with mental health problems in pregnancy, the mixed effects of support, advice and treatment, and the poor perception of staff interaction among women with mental health problems.

IMPLICATIONS FOR PRACTICE

health care professionals may need additional training to effectively support women with mental health problems during the perinatal period.

The Birth Satisfaction Scale-Revised Indicator (BSS-RI)

BACKGROUND

The current study sought to develop a short birth satisfaction indicator utilising items from the Birth Satisfaction Scale-Revised (BSS-R) for use as a brief measure of birth satisfaction and as a possible key performance indicator for perinatal service delivery evaluation. Building on the recently developed BSS-R, the study aimed to develop a simplified version of the instrument to assess birth satisfaction easily that could work as a short evaluative measure of clinical service delivery for labour and birth that is consistent with policy documents, placing women at the centre of the birth experience.

METHODS

The six item Birth Satisfaction Scale-Revised Indicator (BSS-RI) was embedded within the 2014 National Maternity Survey for England. A random selection of mothers who had given birth in a two week period in England were surveyed three months after the birth. Using a two-stage design and split-half dataset, exploratory factor analysis, confirmatory factor analysis, internal consistency, convergent, divergent and known-groups discriminant validity evaluation were conducted in a secondary analysis of the survey data.

RESULTS

Using this large population based survey of recent mothers the short revised measure was found to comprise two distinct domains of birth satisfaction, 'stress and emotional response to labour and birth' and 'quality of care'. The psychometric qualities of the tool were robust as were the indices of validity and reliability evaluated.

CONCLUSION

The BSS-RI represents a short easily administered and scored measure of women's satisfaction with care and the experience of labour and birth. The instrument is potentially useful for researchers, service evaluation and policy makers.

Sociodemographic differences in women's experience of early labour care: a mixed methods study

OBJECTIVES

To explore women's experiences of early labour care focusing on sociodemographic differences, and to examine the effect of antenatal education, using mixed methods.

SETTING

England, 2014.

PARTICIPANTS

Women who completed postal questionnaires about their experience of maternity care, including questions about antenatal education, early labour and sociodemographic factors, included space for free-text comments.

OUTCOME MEASURES

Worries about labour, contact with midwives in early labour and subsequent care.

METHODS

This study was based on secondary analysis of a national maternity survey carried out in England in 2014. Quantitative data were analysed using descriptive statistics and binary logistic regression; qualitative data were analysed using a thematic content analytic approach.

RESULTS

Completed questionnaires were received from 4578 women (47% response rate). There were significant differences by sociodemographic factors, particularly ethnicity, in women's worries about early labour. Compared with white women, women from black or minority ethnic groups had an adjusted OR of 1.93 (95% CI 1.56 to 2.39) of feeling worried about not knowing when labour would start. Among women who contacted a midwife at the start of labour, 84% perceived their advice as appropriate, more in older and multiparous women. Overall, 64% of women were asked to come to the hospital at this time, more in multiparous women (adjusted OR 1.63, 95% CI 1.35 to 1.96). Those who did not have access to antenatal education experienced greater worry about early labour. Five themes emerged from the qualitative analysis: 'Differentiating between early and active labour', 'Staff attitudes', 'Not being allowed…', 'Previous labours' and 'Perceived consequences for women'.

CONCLUSION

These findings reinforce the importance of providing reassurance to women in early labour, taking care that women do not feel neglected or dismissed. In particular, primiparous and ethnic minority women reported greater worry about early labour and require additional reassurance.

Worries About Labor and Birth: A Population-Based Study of Outcomes for Young Primiparous Women

BACKGROUND

Pregnancy at a young age is a continuing public health concern strongly associated with socioeconomic deprivation, social isolation, and stigma. The objectives were to see whether, compared with women aged 21 or more, women aged 20 years or younger worried more about labor and birth, and had poorer maternal outcomes. Another objective was to investigate the extent to which worries about labor and birth mediated the associations between young age and outcomes.

METHODS

A secondary analysis of data was conducted relating to 2,598 primiparous women's experience of maternity care in England in 2010. The survey collected data on care in the antenatal, intrapartum, and postnatal periods, and sociodemographic factors. A validated checklist measured worries about labor and birth.

RESULTS

Compared with women aged 21 or more, women aged 20 years or younger worried more about labor and birth. The pain and duration of labor worried all women and those aged 20 years or younger were particularly worried about the uncertainty of labor onset, cesarean section birth, and about embarrassment. In logistic regression, after adjusting for potential confounders, young age was a significant independent risk factor for worries about pain and distress in labor, and self-reported depression at 1 and 3 months. However, young age was also significantly associated with having a normal vaginal delivery.

CONCLUSIONS

It may be appropriate to focus support on women experiencing multiple disadvantage, rather than young age alone.

Determining the psychometric properties of the Enhancing Decision-making Assessment in Midwifery (EDAM) measure in a cross cultural context

Background

The ability to act on and justify clinical decisions as autonomous accountable midwifery practitioners, is encompassed within many international regulatory frameworks, yet decision-making within midwifery is poorly defined. Decision-making theories from medicine and nursing may have something to offer, but fail to take into consideration midwifery context and philosophy and the decisional autonomy of women. Using an underpinning qualitative methodology, a decision-making framework was developed, which identified Good Clinical Reasoning and Good Midwifery Practice as two conditions necessary to facilitate optimal midwifery decision-making during 2nd stage labour. This study aims to confirm the robustness of the framework and describe the development of Enhancing Decision-making Assessment in Midwifery (EDAM) as a measurement tool through testing of its factor structure, validity and reliability.

Method

A cross-sectional design for instrument development and a 2 (country; Australia/UK) x 2 (Decision-making; optimal/sub-optimal) between-subjects design for instrument evaluation using exploratory and confirmatory factor analysis, internal consistency and known-groups validity. Two ‘expert’ maternity panels, based in Australia and the UK, comprising of 42 participants assessed 16 midwifery real care episode vignettes using the empirically derived 26 item framework. Each item was answered on a 5 point likert scale based on the level of agreement to which the participant felt each item was present in each of the vignettes. Participants were then asked to rate the overall decision-making (optimal/sub-optimal).

Findings

Post factor analysis the framework was reduced to a 19 item EDAM measure, and confirmed as two distinct scales of ‘Clinical Reasoning’ (CR) and ‘Midwifery Practice’ (MP). The CR scale comprised of two subscales; ‘the clinical reasoning process’ and ‘integration and intervention’. The MP scale also comprised two subscales; women’s relationship with the midwife’ and ‘general midwifery practice’.

Conclusion

EDAM would generally appear to be a robust, valid and reliable psychometric instrument for measuring midwifery decision-making, which performs consistently across differing international contexts. The ‘women’s relationship with midwife’ subscale marginally failed to meet the threshold for determining good instrument reliability, which may be due to its brevity. Further research using larger samples and in a wider international context to confirm the veracity of the instrument’s measurement properties and its wider global utility, would be advantageous.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-0882-3) contains supplementary material, which is available to authorized users.

A Rasch-based dimension of delivery experience: spontaneous vs. medically assisted conception

AIMS AND OBJECTIVES

To devise a set of indices representative of a latent dimension of delivery perception, aimed at the assessment of birth experience after both spontaneous and medically assisted conception.

BACKGROUND

Birth experience is of great importance for its prognostic value for the woman and newborn's psychophysical well-being, especially after the experience of assisted reproduction technology. Up to date, a delivery perception assessment measure targeted to both spontaneously and medically assisted conceiving women does not exist yet.

DESIGN

Measure development and psychometric analysis; quantitative and qualitative analysis of women's delivery experience measures.

METHODS

Thirty-one indices characterising seven relevant aspects of birth perception were devised from the literature and evaluated on a 4-point Likert-type scale by 98 childbearing women (54 spontaneously and 44 medically assisted conceiving) in the 24-48 hours postpartum time frame. Women's obstetric history information was also collected. The dimension psychometric definition was pursued within a latent trait perspective, by applying the many-facet Rasch measurement model.

RESULTS

A latent delivery perception dimension composed of 18 valid and reliable indices, qualifying six labour and delivery perception clinical aspects, was identified. Medically assisted conceiving women evidenced a more positive birth perception, but when analysing each index, they showed peculiar intense worries about themselves and their baby's health, even if they felt more satisfied, safer and stronger in almost every labour and birth aspect.

CONCLUSIONS

The delivery perception dimension integrates all relevant birth experience aspects in 18 easy-to-administer indices and provides a valid, reliable and feasible assessment tool for both the clinical practice and research purposes.

RELEVANCE TO CLINICAL PRACTICE

The delivery perception dimension clearly discriminates between women's types of conception and identifies relevant differences in their birth experience, which are interesting for their clinical implications within a prognostic and intervention perspective of support provision in the early postpartum period.

Fathers' engagement in pregnancy and childbirth: evidence from a national survey

Background

Early involvement of fathers with their children has increased in recent times and this is associated with improved cognitive and socio-emotional development of children. Research in the area of father’s engagement with pregnancy and childbirth has mainly focused on white middle-class men and has been mostly qualitative in design. Thus, the aim of this study was to understand who was engaged during pregnancy and childbirth, in what way, and how paternal engagement may influence a woman’s uptake of services, her perceptions of care, and maternal outcomes.

Methods

This study involved secondary analysis of data on 4616 women collected in a 2010 national maternity survey of England asking about their experiences of maternity care, health and well-being up to three months after childbirth, and their partners’ engagement in pregnancy, labour and postnatally. Data were analysed using descriptive statistics, chi-square, binary logistic regression and generalised linear modelling.

Results

Over 80% of fathers were ‘pleased or ‘overjoyed’ in response to their partner’s pregnancy, over half were present for the pregnancy test, for one or more antenatal checks, and almost all were present for ultrasound examinations and for labour. Three-quarters of fathers took paternity leave and, during the postnatal period, most fathers helped with infant care. Paternal engagement was highest in partners of primiparous white women, those living in less deprived areas, and in those whose pregnancy was planned. Greater paternal engagement was positively associated with first contact with health professionals before 12 weeks gestation, having a dating scan, number of antenatal checks, offer and attendance at antenatal classes, and breastfeeding. Paternity leave was also strongly associated with maternal well-being at three months postpartum.

Conclusions

This study demonstrates the considerable sociodemographic variation in partner support and engagement. It is important that health professionals recognise that women in some sociodemographic groups may be less supported by their partner and more reliant on staff and that this may have implications for how women access care.

Who is well after childbirth? Factors related to positive outcome

BACKGROUND

Poor outcomes after childbirth are associated with physical ill health and with an absence of a positive sense of well-being. Postnatally poor physical health is thought to be influenced by the care received, the nature of the birth, and associated complications. The aim of this study was to estimate the effects of a range of clinical and other factors on positive outcome and well-being 3 months after childbirth.

METHODS

This study used data on more than 5,000 women from a 2010 National Maternity Survey about their experiences of maternity care, and health and well-being 3 months after childbirth. Positive outcome was defined as women reporting no problems and feeling "very well" at the time of the survey.

RESULTS

In the univariate analysis, several variables were significantly associated with positive outcome, including sociodemographic, antenatal, intrapartum, and postnatal factors. In the final logistic regression model, young mothers, those without physical disability and those with no or few antenatal or early postnatal problems, were most likely to have positive outcomes. Other significant factors included a positive initial reaction to the pregnancy, not reporting antenatal depression, fewer worries about the labor and birth, and access to information about choices for care.

CONCLUSIONS

This study shows how positive outcomes for women after childbirth may be influenced by health, social, and care factors. It is important for caregivers to bear these factors in mind so that extra support may be made available to those women who are likely to be susceptible to poor outcome.

A review and psychometric evaluation of pregnancy-specific stress measures

Considerable evidence has accumulated on the association between pregnancy-specific stress and adverse birth outcomes with an increasing number of measures of pregnancy-specific stress being developed internationally. However, the introduction of these measures has not always been theoretically or psychometrically grounded, resulting in questions about the quality and direction of such research. This review summarizes evidence on the reliability and validity of pregnancy-specific stress measures identified between 1980 and October 2010. Fifteen pregnancy-specific stress measures were identified. Cronbach's alpha coefficient ranged from 0.51-0.96 and predictive validity data on preterm birth were reported for five measures. Convergent validity data suggest that pregnancy-specific stress is related to, but distinct from, global stress. Findings from this review consolidate current knowledge on pregnancy-specific stress as a consistent predictor of premature birth. This review also advances awareness of the range of measures of pregnancy-specific stress and documents their strengths and limitations based on published reliability and validity data. Careful consideration needs to be given as to which measures to use in future research to maximize the development of stress theory in pregnancy and appropriate interventions for women who experience stress in pregnancy. An international, strategic collaboration is recommended to advance knowledge in this area of study.

Development of the Tilburg Pregnancy Distress Scale: the TPDS

BACKGROUND

Pregnant women with high levels of stress, depression and/or anxiety are at increased risk for adverse perinatal outcomes and impaired neurologic and emotional development of the offspring. Pregnancy specific instruments to measure psychological functioning during gestation are scarce and do not define items based on in-depth interviews of pregnant and recently delivered women. The current study developed a pregnancy specific scale that measures psychological functioning using in-depth interviews.

METHODS

Three focus groups were formed to discuss issues most relevant to pregnancy distress; 22 candidate items were derived for pilot testing (study I, n = 419) its psychometric properties by means of explorative factor analyses (EFA). This resulted in a 17-item TPDS which was further explored by confirmatory factor analyses (CFA) and concurrent and construct validity assessment (study II, n = 454).

RESULTS

EFA in study I suggested a two component solution (negative affect (NA) and partner involvement (PI)). CFA in study II resulted in a higher order model of the NA subscale into three more subscales: NA regarding confinement, delivery and general health. TPDS, EPDS and GAD-7 were all significantly correlated.

CONCLUSIONS

The TPDS constitutes a valid and user friendly instrument to assess pregnancy distress. In addition to its proven ability to pick up pregnancy specific negative affect it also includes an important sub-scale measuring perceived partner involvement.

Ethnic differences in women's worries about labour and birth

OBJECTIVE

To describe the worries experienced by pregnant Black and Minority Ethnic (BME) women about labour and birth and compare their experience to that of White women.

DESIGN

Data were collected in England in a survey of experience of maternity care. A random sample of 4800 women selected from birth registration records and questionnaires were mailed at three months postpartum. A total of 2960 (63%) completed a checklist of common worries about labour and birth. For 2765 there were complete data on ethnicity and all potential confounders. Chi(2) tests and logistic regression models were used to investigate the associations of ethnicity with worries about labour. Unadjusted and adjusted models were run for each worry outcome. Adjustment was made for age, education, parity, relationship status and area deprivation (Index of Multiple Deprivation, IMD).

RESULTS

Overall, the pattern of worries was similar, however, larger proportions of BME women worried about almost all the aspects of labour and birth investigated, including pain, uncertainty about labour onset and duration, possible medical interventions and embarrassment. After adjustment for age, education, relationship status, parity and socioeconomic position, the higher odds of worry in the BME group were most marked in relation to pain and discomfort, not knowing how long labour would take, embarrassment and having more worries overall. Further adjustment for factors likely to affect women's worries, namely depression, being admitted to hospital during the pregnancy, or having experienced medical problems in a previous pregnancy did not alter these findings.

CONCLUSION

Compared with White women, twice as many ethnic minority women worried about pain and discomfort, not knowing how long labour would take and about embarrassment during labour and birth. Additional research is needed to understand these concerns and how they might be ameliorated by the health professionals working directly with women and any services changes needed to improve the quality of maternity care. Implications for practice include improved information-giving and support in providing the individualised care that women need.