A Longitudinal Survey of Childbirth‐Related Fear and Associated Factors

Pre- and postpartum fear of childbirth and its predictors among rural women in China

BACKGROUND

Fear of childbirth (FOC) can influence both maternal and child health. Research on FOC in China is scarce, especially on rural women. This study aimed to assess pre- and postpartum FOC and its predictors among Chinese rural women.

METHODS

This was a prospective correlation study. A total of 569 women completed the prenatal questionnaire in the third trimester, and 477 of them completed the postpartum questionnaire within three days after childbirth. Maternal socio-demographic information, clinical information, childbirth self-efficacy and prenatal and postpartum FOC were investigated. FOC was evaluated using the Wijma Childbirth Expectancy/ Experience Questionnaire (WDEQ). Descriptive, bivariate, multivariate linear regression analysis, univariate and multivariate logistic regression analyses were performed.

RESULTS

The mean pre- and postpartum FOC scores were 64.5 (standard deviation: 25.1) and 64.3 (standard deviation: 23.9), respectively, with 20.8% of women reporting severe fear before childbirth and 18.2% after childbirth. Multivariate linear regression analysis revealed predictors for higher levels of prenatal FOC including higher education level, nullipara, higher monthly household income, lower family support, and lower childbirth self-efficacy (p < 0.05) and the predictors for higher levels of postpartum FOC included unemployed status, lower childbirth self-efficacy, and higher prenatal FOC (p < 0.05). Multivariate logistic regression showed that higher childbirth self-efficacy reduced the likelihood of severe prenatal FOC (OR: 0.99, p < 0.001), while severe prenatal FOC increased the likelihood of severe postpartum FOC (OR: 3.57, p < 0.001).

CONCLUSION

The rural women have high levels of FOC before and after childbirth, with approximately 20% experiencing severe FOC during both periods. Higher education level, nullipara, higher monthly household income, lower family support, and lower childbirth self-efficacy are predictors of heightened prenatal FOC. Unemployed status, lower childbirth self-efficacy, and higher prenatal FOC are predictors of heightened postpartum FOC. Notably, enhancing childbirth self-efficacy emerges as crucial in mitigating severe prenatal FOC, while severe prenatal FOC significantly increases the likelihood of severe postpartum FOC. The development of targeted intervention strategies for the above factors can help reduce women's FOC level and improve their overall pregnancy and childbirth experience.

Going through it together: Dyadic associations between parents' birth experience, relationship satisfaction, and mental health

BACKGROUND

Previous research suggests that a negative birth experience is associated with symptoms of postpartum depression and anxiety in mothers and partners. However, this has mostly been investigated within the first year postpartum and research on the long-term effects is lacking. Additionally, the role of relationship satisfaction and the interdependence between parents have not been considered so far.

METHODS

Couples (N = 1992) completed questionnaires on their birth experience, relationship satisfaction, and symptoms of depression and anxiety at two months, 14 months, and two years after birth, respectively.

RESULTS

Actor-Partner Interdependence Mediation Models indicated no partner effects, but several significant actor and indirect effects. A more positive birth experience was associated with higher relationship satisfaction and less depression and anxiety symptoms for both parents. Higher relationship satisfaction was in turn associated with less depression (mothers and partners) and anxiety symptoms (mothers). The association between birth experience and depression symptoms was partially mediated by relationship satisfaction for mothers and partners, while the association between birth experience and anxiety symptoms was partially mediated by relationship satisfaction only for mothers.

LIMITATIONS

Due to the highly educated, very healthy sample with low levels of depression and anxiety as well as high relationship satisfaction, results cannot be generalized to less privileged parents. Moreover, all effects were very small.

CONCLUSIONS

Results highlight the importance of a positive birth experience for parents' relationship satisfaction and mental health. Negative birth experiences need to be avoided to prevent a negative impact on the whole family.

The prevalence and associated factors of fear of childbirth among Turkish pregnant women

OBJECTIVE

This study was conducted to determine the prevalence of fear of childbirth and affecting factors in pregnant women in Turkey.

MATERIALS AND METHODS

This was a cross-sectional study and included a total of 2025.    Pregnant Women Assessment, some variables related to previous and current perinatal processes and Wijma Delivery Expectancy/Experience Questionnaire (version A) were used for data collection.

FINDINGS

In this sample, 42.4% of the women reported fear of childbirth. What the women were afraid of most was the development of unwanted conditions at childbirth, obscurity/uncertainty, and negative attitudes of health professionals. The factors causing fear of childbirth were the low education level, unemployment status, low financial status, stillbirth, unplanned pregnancy, indecisiveness about the type of delivery, not attending prenatal education programs, negative effects of other people, insufficient social support, confiding in the healthcare centre and health professional, negative, and indecisive birth perceptions, prior negative birth experiences and not feeling ready for childbirth (p < 0.001).

CONCLUSIONS

The prevalence of fear of childbirth in this Turkish sample, especially in the multipara is higher than in Western countries. Causes of fear of childbirth can vary with countries and even with each region of a country.

Translation and validation of the Czech Republic version of the Birth Satisfaction Scale-Revised (BSS-R)

BACKGROUND

Satisfaction with the birth experience has been established to be critical for the wellbeing of the mother. The Birth Satisfaction Scale-Revised (BSS-R) is a brief and psychometrically robust multi-dimensional self-report tool designed to assess birth experience. The current investigation sought to translate and validate a Czech Republic version of the BSS-R (CZ-BSS-R).

METHODS

Following translation psychometric assessment of the CZ-BSS-R was undertaken using a cross-sectional design. A between-subjects design was incorporated in order to evaluate known-groups validity evaluation of the translated measure. Four hundred and sixty-five Czech-speaking women within the Czech Republic took part in the study. Confirmatory factor analysis was undertaken and divergent and convergent validity and internal consistency characteristics also evaluated.

RESULTS

The CZ-BSS-R was observed to have excellent psychometric properties and conceptually and measurement faithful to the original English-language measure. Consistent with previous investigations using the BSS-R significant differences were found in scores as a function of delivery type.

CONCLUSIONS

The CZ-BSS-R is a valid, robust and reliable measure of birth experience and suitable for use with Czech-speaking women in the Czech Republic. The study highlighted that instrument and emergency Caesarean section were associated with a lower level of birth satisfaction compared to vaginal delivery.

The choice of Caesarean section between clinical indication and patient autonomy: The physician between rock and hard place

RATIONALE, AIMS AND OBJECTIVES

Caesarean delivery carries a higher risk of short- and long-term complications for both mother and baby than vaginal delivery. However, over the past two decades, data show a considerable increase in requests for Caesarean sections. This manuscript analyses the case of Caesarean Section on maternal request without a clinical indication from a medico-legal and ethical perspective.

METHOD

Medical associations and bodies databases were searched for published guidelines and recommendations on the use of caesarean sections on maternal requests. As derived from the literature, medical risks, attitudes, and reasons for this choice have also been summarized.

RESULTS

International guidelines and medical associations recommend strengthening the doctor-patient relationship by setting up an information process to make the pregnant woman understand the danger of Caesarean delivery without clinical indications and to make her consider whether she can survive natural childbirth.

CONCLUSION

Caesarean section on maternal request and without clinical indications is an emblematic case of how the physician could be between two opposing interests. Our analysis shows that if the woman's rejection of natural birth persists and clinical indications for Caesarean delivery are lacking, the physician must respect the patient's choice.

Exploring Western Australian Women's experiences of sharing positive birth stories

BACKGROUND

Fear can impact childbirth experiences, yet most birth stories women hear portray birth as unfavourable, and women must actively seek out positive birth stories.

AIMS AND OBJECTIVES

We aim to explore how women feel when sharing positive birth stories and the socially constructed motivations for or against sharing.

RESEARCH QUESTION

What are the experiences of women who share positive birth stories?

METHODS

A qualitative descriptive approach was adopted, adhering to Standards of Reporting Qualitative Research (SRQR) guidelines, and underpinned by an interpretivist research philosophy. Participants were recruited via Facebook using a non-probability, voluntary-response, purposive sampling method. Twelve English-speaking Western Australian women aged 24-38 years identified as having had a positive vaginal birth experience within the past 5 years. Semi-structured interviews were transcribed verbatim and analysed using thematic analysis.

FINDINGS

The theme Not Safe to Share and sub-themes The Perils of Sharing and Changing the Narrative explores how participants repeatedly felt unable to share their birth stories because society's dominant view of childbirth was negative. It describes the experienced or anticipated reactions that contributed to feeling unsafe and how participants withheld or altered their stories to feel accepted. The theme Safe Spaces and sub-theme The Joys of Sharing, explored participants' love of sharing their birth stories in safe spaces, allowing re-access to feelings of elation, validation of their stories, and opportunity to empower others.

CONCLUSIONS

Women often feel reluctant to share their positive birth stories. Findings may help understand the lack of availability of positive birth stories in our society. Normalising the positive birth experience may improve the experience of sharing positive birth stories, potentially improving society's view of childbirth.

High/severe fear of childbirth and related risk factors among pregnant women: is vaginismus a risk factor?

This study aimed to investigate the prevalence of fear of childbirth (FOC) and associated factors including vaginismus in pregnant women with high/severe FOC. In the study, 407 women who were at 24-40 weeks of gestation were included. The Wijma Delivery Expectancy/Experience Questionnaire Version A (WDEQA), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and vaginismus sub-scale of the Golombok Rust inventory of sexual satisfaction (GRISS) were used. 186 (46%) participants had high/severe FOC. Pregnant women with high/severe FOC had a significantly higher fear of pain during sexual intercourse, higher scores in the WDEQA, BDI, BAI, and vaginismus sub-scale of GRISS. Depression and anxiety level, educational level, access to information on delivery during pregnancy, presence of medical disease, and expression of FOC were predictors of high/severe FOC. Assessment of FOC and associated risk factors, including vaginismus, during pregnancy, will enable the identification of risk groups and the creation of support programmes.Impact StatementWhat is already known on this subject? The range of fear of childbirth (FOC) changes from mild anxiety to severe fear. The prevalence and severity of FOC and related risk factors vary in the studies due to cultural factors, differences in the definition of FOC and measurement tools. The relationship between FOC and vaginismus has not been sufficiently investigated.What do the results of this study add? This study aimed to investigate the prevalence of fear of childbirth (FOC) and associated factors including vaginismus in pregnant women with high/severe FOC.What are the implications of these findings for clinical practice and/or further research? This is the first study that evaluates vaginismus as a risk factor for FOC. Assessment of FOC and associated risk factors, including vaginismus, in pregnant women, will enable the identification of risk groups and the creation of support programs for risk reduction.

Caesarean Section on Maternal Request-Ethical and Juridic Issues: A Narrative Review

In recent decades, the rate of caesarean deliveries has increased worldwide. The reasons for this trend are still largely misunderstood and controversial among researchers. The decision often depends on the obstetrician, his beliefs and experience, the characteristics of the patients, the hospital environment and its internal protocols, the increasing use of induction of labor, the medico-legal implications, and, finally, the mother’s ability to request delivery by caesarean section without medical indication. This review aims to describe the reasons behind the increasing demand for caesarean sections by patients (CDMR) and strategies aimed at reducing caesarean section rates and educating women about the risks and benefits of CS.

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.

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.

The Role of Personality Traits and Delivery Experience in Fear of Childbirth: A Prospective Study

This study aimed to examine fear of childbirth (FOC) before and after delivery in relation to personality (anxiety and anxiety sensitivity) and birth experience (type of delivery, pain, and staff support). One-hundred and five women completed questionnaires during pregnancy and one month after childbirth. Participants completed the Wijma Delivery Expectancy/Experience Questionnaire; the State and Trait Anxiety Inventory and Anxiety Sensitivity Index, and the McGill Pain Questionnaire and a Support from staff questionnaire. FOC levels decreased after childbirth, but only in the high-level fear group. Path analysis showed that physical concerns, one aspect of anxiety sensitivity, shape FOC during pregnancy. Together with interventions at delivery (instrumental vaginal delivery and emergency caesarean section), pain and low staff support, this in turn modifies FOC after delivery. In conclusion, FOC decreases after childbirth. However, combined with adverse birth experience and certain personality traits, FOC during pregnancy affects FOC after delivery.

Fear of childbirth in Iran: A systematic review of psychological intervention research

Background

Due to the fear of childbirth (FOC) and failure to provide painless delivery in Iran, the prevalence rate of elective cesarean section (C-section) performed on request by pregnant women is on the rise. However, no systematic review assessing the results of studies in this respect has been thus far developed.

Objective

To systematically review published psychological intervention research reflecting on FOC in Iran.

Materials and Methods

In this systematic review, the databases of PubMed, MEDLINE, PsycINFO, Wiley, ISI Web of Science, Scopus, Science Direct, Cochrane Library, Google Scholar, and Scientific Information Database were searched to retrieve the relevant studies. Manual searches were performed to find the relevant articles and finally 21 intervention studies were reviewed.

Results

Based on the modified Jadad Scale, a methodological quality (risk of bias) assessment tool, 14 and 7 studies had acceptable or good and low quality, respectively. The included articles covered fear, fear of childbirth, pregnancy, and psychological intervention in Iran. Cognitive behavioral therapy, relaxation techniques, psychological counseling, childbirth preparation classes (CPCs), mindfulness programs, and psychoeducation had been also practiced as the main types of psychological interventions for reducing FOC in pregnant women.

Conclusion

There was no clear evidence to establish the most effective method for minimizing levels of FOC in pregnant women. Based on the assessment tool and since most of the studies had moderate or low quality, conducting standard and high-quality randomized controlled trials focusing on FOC in pregnant women is of most importance in Iranian population.

When Fear Surrounding Childbirth Leads Women to Request a Planned Cesarean Birth

Fear surrounding childbirth requires a more in-depth understanding from women’s perspectives, especially those who request a planned cesarean due to that fear. Therefore, we explored primiparous and multiparous women’s lived experiences of fear surrounding childbirth in relation to their decision to request a planned cesarean birth. We used Colaizzi’s (1978) phenomenological method to interview 16 women from 4 provinces and to analyze the data. Women expressed numerous fears and most experienced more than one fear. Most feared their baby/babies being injured or dying during childbirth or developing complications themselves. Others feared experiencing a traumatic birth. Women described numerous emotional and physical manifestations of fear, and all believed that a planned cesarean birth would provide more control over the birth process. For some, the birth of their healthy baby/babies began a healing process, whereas others noted that their fear subsided or resolved upon confirmation that they would have a planned cesarean.

Treatment of Pregnant Women With Fear of Childbirth Using EMDR Therapy: Results of a Multi-Center Randomized Controlled Trial

Fear of childbirth (FoC) occurs in 7. 5% of pregnant women and has been associated with adverse feto-maternal outcomes. Eye Movement Desensitization and Reprocessing (EMDR) therapy has proven to be effective in the treatment of posttraumatic stress disorder (PTSD) and anxiety; however, its effectiveness regarding FoC has not yet been established. The aim was to determine the safety and effectiveness of EMDR therapy for pregnant women with FoC. This single-blind RCT (the OptiMUM-study, www.trialregister.nl, NTR5122) was conducted in the Netherlands. FoC was defined as a score ≥85 on the Wijma Delivery Expectations Questionnaire (WDEQ-A). Pregnant women with FoC and a gestational age between 8 and 20 weeks were randomly assigned to EMDR therapy or care-as-usual (CAU). The severity of FoC was assessed using the WDEQ-A. Safety was indexed as worsening of FoC symptoms, dropout, serious adverse events, or increased suicide risk. We used linear mixed model analyses to compare groups. A total of 141 women were randomized (EMDR n = 70; CAU n = 71). No differences between groups were found regarding safety. Both groups showed a very large (EMDR d = 1.36) or large (CAU d = 0.89) reduction of FoC symptoms with a mean decrease of 25.6 (EMDR) and 17.4 (CAU) points in WDEQ-A sum score. No significant difference between both groups was found (p = 0.83). At posttreatment, 72.4% (EMDR) vs. 59.6% (CAU) no longer met the criteria for FoC. In conclusion, the results are supportive of EMDR therapy as a safe and effective treatment of FoC during pregnancy, albeit without significant beneficial effects of EMDR therapy over and above those of CAU. Therefore, the current study results do not justify implementation of EMDR therapy as an additional treatment in this particular setting.

Maternal perinatal depression, anxiety, fear of birth, and perception of infants' negative affectivity at three months

The present study aimed to investigate whether a mother's anxiety, depression, prenatal perception of childbirth, and experience with delivery, assessed from pregnancy to three months postpartum, were associated with her perception of her infant's negative affectivity (NA). The participant sample was composed of 76 primiparous mothers and their healthy babies (58% boys, 42% girls). During pregnancy, mothers independently filled out the State-Trait Anxiety Inventory (STAI), the Edinburgh Postnatal Depression Scale (EPDS), and the Wijma Delivery Expectancy/Experience Questionnaires (W-DEQ) version A. One month after giving birth, the mothers filled out the W-DEQ version B. Finally, three months after giving birth, they completed the EPDS, the STAI, and the four Infant Behaviour Questionnaire (IBQ-R) scales of NA. Linear regression analyses showed that perinatal FoB, trait anxiety, and depression were associated with a maternal perception of higher infant NA. Studies on perinatal parental health and child outcomes should include assessments of the relation between anxiety during pregnancy and postpartum depression in order to prevent any negative impacts on the temperaments of children.

A continuity of care project with two on-call schedules: Findings from a rural area in Sweden

BACKGROUND

In many countries, various continuity models of midwifery care arrangements have been developed to benefit women and babies. In Sweden, such models are rare.

AIM

To evaluate two on-call schedules for enabling continuity of midwifery care during labour and birth, in a rural area of Sweden.

METHOD

A participatory action research project where the project was discussed, planned and implemented in collaboration between researchers, midwives and the project leader, and refined during the project period. Questionnaires were collected from participating women, in mid pregnancy and two months after birth.

RESULT

One of the models resulted in a higher degree of continuity, especially for women with fear of birth. Having a known midwife was associated with higher satisfaction in the medical (aOR 2.02 (95% CI 1.14-4.22) and the emotional (aOR 2.05; 1.09-3.86) aspects of intrapartum care, regardless of the model.

CONCLUSION

This study presented and evaluated two models of continuity with different on-call schedules and different possibilities for women to have access to a known midwife during labour and birth. Women were satisfied with the intrapartum care, and those who had had a known midwife were the most satisfied. Introducing a new model of care in a rural area where the labour ward recently closed challenged both the midwives' working conditions and women's access to evidence-based care.

Traumatic anticipation of childbirth and disordered eating during pregnancy

BACKGROUND

While research on Fear Of Childbirth (FOC) during pregnancy is on the rise, research regarding pretraumatic stress reactions is lacking. Moreover, less is known regarding negative anticipation of childbirth and Eating Disorders (ED). This study aims at identifying typologies of women in the prepartum period based on FOC and pretraumatic stress symptoms and investigating whether or not the identified profiles differ on levels of bulimic symptoms and Drive for Thinness (DT).

PARTICIPANTS AND METHODS

a sample of 213 pregnant women completed questionnaires assessing FOC, pretraumatic stress, DT and bulimic symptoms.

RESULTS

four clusters based on pretraumatic stress and FOC symptoms were identified: one characterised by traumatic symptoms, one showing moderated FOC symptoms, one with high symptomatology and one with low symptoms. Higher ED symptoms were found in women with both FOC and pretraumatic stress symptoms, and in the cluster showing elevated pretraumatic stress symptomatology.

CONCLUSIONS

To our knowledge, this is the first study focusing on anticipated traumatic reactions and ED in pregnant women. While some women evidenced FOC and pretraumatic stress symptoms, two different clusters, one with FOC and one with pretraumatic stress, were found. These findings suggest that, while sharing similarities, these constructs are different.

How do personality characteristics of risky pregnant women affect their prenatal distress levels?

Purpose

The prenatal distress level of the pregnant woman is influenced by many variables. Personality characteristics are one of the most important of these variables. Knowing personality characteristics of pregnant women contributes to the personalization of care. The purpose of this paper is to identify the effect of personality characteristics of pregnant women at risk on the prenatal distress level.

Design/methodology/approach

A total of 438 women who were hospitalized based on a medical diagnosis associated with pregnancy were included in the study. The participants were administered the Personal Information Form, Cervantes Personality Scale and Revised Prenatal Distress Questionnaire. Data were evaluated using the SPSS 22.0 software program.

Findings

Of the pregnant women, 27.4 percent found their ability to cope with stress insufficient, and one-fifth of them found their social support insufficient. The pregnant women at risk with introverted, neurotic and inconsistent personality were found to have high levels of prenatal distress.

Research limitations/implications

This study was conducted on a group of Turkish pregnant women and cannot be generalized to other cultures. The data obtained from the research cannot be used to evaluate the psychological and physical disorders of the pregnant woman.

Practical implications

All health care professionals should evaluate women not only physically but also mentally and emotionally, beginning with the preconceptional period. They should determine the conditions that create distress and identify the personality characteristics that prevent from coping with stress. By using cognitive and behavioral techniques, pregnant women should be trained to gain skills on subjects such as risk perception and stress management, personality characteristics and coping, problem solving, psychological endurance and optimism. Caring initiatives should be personalized in line with personality characteristics of pregnant women. The care offered within this framework will contribute to the strengthening and development of the health of not only the women but also the family and society, and to the reduction of health care costs.

Social implications

Researchers have determined that pregnant women at risk with introverted, neurotic and inconsistent personality characteristics have higher distress levels. They have determined that these pregnant women find their ability to cope with stress more inadequate. It is vital to cope with stress during pregnancy due to its adverse effects on maternal/fetal/neonatal health.

Originality/value

The prenatal distress level of the pregnant woman is influenced by many demographic (age, marital status and socioeconomic level), social (marital dissatisfaction, and lack of social support), personal (self-esteem, neuroticism and negative life experiences) and pregnancy-related (experiencing risky pregnancy, and previous pregnancy experiences) variables. Personality characteristics are one of the most important of these variables. This research is original because there are limited number of studies examining the effect of personality characteristics on prenatal distress level in the literature. And knowing the relationship between personality characteristics and distress by health professionals enables individualization of care. The care offered within this framework will contribute to the strengthening and development of the health of not only the women, but also the family and society, and to the decrease of health care costs.

Association between antenatal classes attendance and perceived fear and pain during labour

OBJECTIVES

Antenatal classes are a common method of preparation for birth with proven efficiency in improving perinatal outcomes. Yet, their impact on fear perception during labour has not been identified. The aim of the study was to analyse whether preparation for labour by means of antenatal classes attendance could be associated with decrease in level of experienced fear and pain during birth.

MATERIALS AND METHODS

It was a cross-sectional study of 147 women who had given vaginal births. Data was collected from mothers between 24 and 72 h postpartum. Patients answered self-reported questionnaires concerning subjective perception of birth including Delivery Fear Scale (DFS) and Numeric Rating Scale (NRS) for fear and pain assessment. The study group was divided into subgroups depending on parity and antenatal classes attendance.

RESULTS

Patients in the primiparas subgroup who attended antenatal classes scored lower in the DFS (48.7 ± 23.5 vs. 60.2 ± 16.5, p < .03). There was no difference in the DFS score in the multiparas subgroup (p < .90). No significant differences in the NRS score depending on antenatal classes attendance in any subgroup were observed.

CONCLUSION

Participation in antenatal classes should be advised to every pregnant primiparous woman as this type of non-invasive preparation lowers level of fear experienced during childbirth.

Fear of childbirth from the perspective of midwives working in hospitals in Norway: A qualitative study

AIM

To illuminate the perceptions of hospital-based midwives who support women suffering from moderate to severe fear of childbirth during an expected vaginal birth.

DESIGN

A qualitative descriptive and explorative study.

METHODS

Focus group interviews were conducted with 18 midwives representing four different hospitals in Norway.

RESULTS

Encountering fear of childbirth evoked the desire to protect and help, although the ability to provide optimal support was dependent on several circumstances, several of which were beyond the midwives̕ control. The main theme "Midwives finding their own strength when encountering the vulnerability of women with fear of childbirth" consisted of two themes: "Being present" and "Being alone." The midwives described being present as a prerequisite for continuity of care and affirmation. The emphasis on continuity of care could give rise to a sense of loneliness and guilt during and after demanding situations in the birthing room.

Comparing the course of anxiety in women receiving their first or repeated caesarean section: A prospective cohort study

BACKGROUND

Around 30% of births are through caesarean section and repetition rates for receiving a caesarean section are high.

AIM

The aim of the prospective study was to compare the course of anxiety in women undergoing their first caesarean section and women experiencing a repeated caesarean section.

PARTICIPANTS

304 women with an indication for an elective caesarean section took part. 155 received their first caesarean section and 149 received a repeated caesarean section.

METHODS

In order to measure the course of anxiety on the day of the caesarean section subjective anxiety levels were measured and saliva samples for cortisol determination were taken at admission, during skin closure and two hours after the surgery. Blood pressure and heart rate were documented at skin incision and skin closure.

RESULTS

Women experiencing their first caesarean section displayed significantly higher anxiety levels compared to women with a repeated caesarean section. Scores of the STAI-State and visual analogue scale for anxiety differed significantly at admission (p=.006 and p<.001) and heart rate and alpha amylase levels were significantly higher at skin closure (p=.027 and p=.029).

CONCLUSION

The results show that previous experience with a caesarean section has a soothing effect. The study aims to sensitize surgeons, anesthetists, nurses and midwives when treating women receiving a caesarean section and encourage them to incorporate soothing interventions, especially for women receiving their first caesarean section to reduce anxiety levels and consequently improve postoperative recovery and patients' satisfaction.

Obstetric complications in bipolar disorder: The role of mental health disorders in the risk of caesarean section

BACKGROUND

Women with Bipolar Disorder (BD) during pregnancy present a negative impact on them and their babies' health. Caesarean Section (C-Section) is an intervention to reduce complications associated with childbirth, but it also has risks, including maternal infections, anaesthetic and psychological complications. There are few studies that analyse the C-Section rates in women with BD compared to the general population.

METHODS

A case-control study was conducted in a general university hospital. 100 pregnant women with BD matched with 100 controls without psychiatric illness who were attending the same hospital at delivery. We compared obstetrical outcomes during pregnancy, Pre/During Labour, onset of labour and mode of delivery specifying the type of C-Section.

RESULTS

Rate of C-Section was significantly higher in BD group compared to the control group (OR=2, 95% CI 1,4-1,6). Case group had more somatic illness (SI) without treatment (P<, 001). BD (P=,021), primiparity (P=, 003), obstetric complications during pregnancy (P<, 001), obstetric complications during labour (P<,001), and SI with and without treatment (P<,001 and P=,007, respectively) were higher in women that required C- section.

CONCLUSION

Women with Bipolar Disorder have near two-fold increased risk of C-section than women without Bipolar Disorder of similar age, gestational age and parity. Somatic illness was more prevalent in BD group that required C-section and this relation probably is related to high probability of having somatic comorbidities in patients with BD.

When Fear of Childbirth is Pathological: The Fear Continuum

OBJECTIVES

Given that prepartum psychiatric symptoms have been reported to be associated with postpartum disorders, focusing on the prepartum period appears of prime importance. The aim of the current study was threefold: (a) to identify the prevalence rates of women suffering from fear of childbirth (FOC) and tokophobia (b) to explore the association between FOC, obstetrical and psychopathological variables and (c) to identify the independent predictors of the intensity of FOC symptoms, FOC and tokophobia.

METHODS

at 36 weeks' gestation, 98 women completed questionnaires assessing FOC, pretraumatic stress, fear of pain, depressive and anxiety symptomatology as well as perceived social support. Socio-demographic and gynecological data were also gathered.

RESULTS

22.45% of women reported a probable FOC and 20.41% suffered from a potential tokophobia. Epidural anesthesia (ß = 5.62, p < 0.05), and the intensity of pretraumatic stress symptoms (ß= 0.69, p < 0.05), were independently associated with the intensity of FOC symptoms. Planning a c-section was significantly related to FOC (β = 0.09, p = 0.03). Planning an epidural anesthesia was also an independent predictor of both FOC and tokophobia (β = 1.33, p = 0.03; β = 1.26, p = 0.04, respectively).

CONCLUSIONS

Given the high rates of FOC and tokophobia highlighted, developing an appropriate preparation to childbirth is of great relevance. Longitudinal studies should be developed in order to provide an in-depth examination of the course of prepartum psychiatric disorders, maintenance of symptoms and their impact on subsequent infant development.

Reasons for elective cesarean section on maternal request: a systematic review

Background: Given the increasing rate of cesarean delivery and request without maternal or fetal indication among pregnant women, this systematic review was conducted to obtain the reasons for maternal request for elective cesarean section.Methods: We searched published studies from the first year of records through August 2018 in PubMed, Scopus, and Web of Science. The quality assessment of the studies was performed by the improved Newcastle-Ottawa Scale. Due to data heterogeneity; no meta-analysis was performed.Results: Twenty-eight studies met the inclusion criteria and were included in the review. The results of studies on the reasons of maternal request for elective cesarean section were fear of labor pain, anxiety for fetal injury/death, fear of childbirth, urinary incontinence, pelvic floor and vaginal trauma, doctors suggestion, time of birth, experience of prior bad delivery, previous infertility, infertility, anxiety for gynecologic examination, anxiety for loss of control, avoid long labor, anxiety for lack of support from the staff, fear of fecal, emotional aspects, body weight of the infant at birth and abnormal prenatal examination. The results of studies on the demographic reasons of maternal request for elective cesarean section were advanced maternal age, parity, occupation, education, maternal obesity, family status, decreasing level of religiosity, household income, number of living children and age at marriage.Conclusions: Our study proposed that the comprehensive programs and the interventions of health promotion should be designed to reduce unnecessary cesarean section and improve the performance of vaginal delivery.

Reproduction, fear of childbirth and obstetric outcomes in women treated for fear of childbirth in their first pregnancy: A historical cohort

INTRODUCTION

About 8% of the pregnant women in Sweden receive counseling for fear of childbirth (FOC) during pregnancy. Little is known about the long-term reproductive and obstetric outcomes after counseling for FOC: Therefore, the objective of this historical cohort study was to compare the long-term reproductive and obstetric outcomes in women treated for FOC in their first pregnancy to women without FOC.

MATERIAL AND METHODS

All nulliparas consecutively referred for treatment of severe FOC between 2001 and 2007 (n = 608) were compared with all other nulliparas giving birth on the same day (n = 431). Women who were not fluent in Swedish, missing a postal address, had moved out of the area, given birth at another hospital or had a late spontaneous abortion were excluded (n = 555). A total of 235 women agreed to participate in the study, 63 (39%) women in the index group and 172 (53%) in the reference group. The women were contacted by letter in 2015, ie 7-14 years after first childbirth, and asked to permit access to their medical charts from pregnancies and childbirths and to fill out a study specific questionnaire. Based on data from the medical charts and questionnaire, the mode of delivery, birth experience, obstetric complications, FOC, counseling for FOC and number of childbirths were compared in the two groups.

RESULTS

Women in the index group less often gave birth more than twice compared with the reference group (8.2% vs 22.0%, P = 0.012). We found no significant differences in complications during subsequent pregnancies and deliveries. Women in the index group more often gave birth by CS in their first (P = 0.002) and second childbirth (P = 0.001), more often had a less positive birth experience (index group NRS: median 6.0, interquartile range 6 vs reference group NRS: 7.0, interquartile range 5, P = 0.004) in their first delivery and more often received counseling for FOC (58.7% vs 12.5%, P < 0.001) in subsequent pregnancies. Women in the index group more often experienced FOC (18% vs 5.3%, P = 0.001) 7-14 years after first childbirth.

CONCLUSIONS

FOC is not easily treated. Despite treatment and exposure to childbirth many women received treatment in their next pregnancy and still suffered from FOC 7-14 years after the first childbirth.

Comparing Internet-Based Cognitive Behavioral Therapy With Standard Care for Women With Fear of Birth: Randomized Controlled Trial

BACKGROUND

Although many pregnant women report fear related to the approaching birth, no consensus exists on how fear of birth should be handled in clinical care.

OBJECTIVE

This randomized controlled trial aimed to compare the efficacy of a guided internet-based self-help program based on cognitive behavioral therapy (guided ICBT) with standard care on the levels of fear of birth in a sample of pregnant women reporting fear of birth.

METHODS

This nonblinded, multicenter randomized controlled trial with a parallel design was conducted at three study centers (hospitals) in Sweden. Recruitment commenced at the ultrasound screening examination during gestational weeks 17-20. The therapist-guided ICBT intervention was inspired by the Unified protocol for transdiagnostic treatment of emotional disorders and consisted of 8 treatment modules and 1 module for postpartum follow-up. The aim was to help participants observe and understand their fear of birth and find new ways of coping with difficult thoughts and emotions. Standard care was offered in the three different study regions. The primary outcome was self-assessed levels of fear of birth, measured using the Fear of Birth Scale.

RESULTS

We included 258 pregnant women reporting clinically significant levels of fear of birth (guided ICBT group, 127; standard care group, 131). Of the 127 women randomized to the guided ICBT group, 103 (81%) commenced treatment, 60 (47%) moved on to the second module, and only 13 (10%) finished ≥4 modules. The levels of fear of birth did not differ between the intervention groups postintervention. At 1-year postpartum follow-up, participants in the guided ICBT group exhibited significantly lower levels of fear of birth (U=3674.00, z=-1.97, P=.049, Cohen d=0.28, 95% CI -0.01 to 0.57). Using the linear mixed models analysis, an overall decrease in the levels of fear of birth over time was found (P≤ .001), along with a significant interaction between time and intervention, showing a larger reduction in fear of birth in the guided ICBT group over time (F_1,192.538=4.96, P=.03).

CONCLUSIONS

Fear of birth decreased over time in both intervention groups; while the decrease was slightly larger in the guided ICBT group, the main effect of time alone, regardless of treatment allocation, was most evident. Poor treatment adherence to guided ICBT implies low feasibility and acceptance of this treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02306434; https://clinicaltrials.gov/ct2/show/NCT02306434 (Archived by WebCite at http://www.webcitation.org/70sj83qat).

A systematic review of nonpharmacological prenatal interventions for pregnancy-specific anxiety and fear of childbirth

BACKGROUND

Despite a sharp increase in the number of publications that report on treatment options for pregnancy-specific anxiety and fear of childbirth (PSA/FoB), no systematic review of nonpharmacological prenatal interventions for PSA/FoB has been published. Our team addressed this gap, as an important first step in developing guidelines and recommendations for the treatment of women with PSA/FoB.

METHODS

Two databases (PubMed and Mendeley) were searched, using a combination of 42 search terms. After removing duplicates, two authors independently assessed 208 abstracts. Sixteen studies met eligibility criteria, ie, the article reported on an intervention, educational component, or treatment regime for PSA/FoB during pregnancy, and included a control group. Independent quality assessments resulted in the retention of seven studies.

RESULTS

Six of seven included studies were randomized controlled trials (RCTs) and one a quasi-experimental study. Five studies received moderate quality ratings and two strong ratings. Five of seven studies reported significant changes in PSA/FoB, as a result of the intervention. Short individual psychotherapeutic interventions (1.5-5 hours) delivered by midwives or obstetricians were effective for women with elevated childbirth fear. Interventions that were effective for pregnant women with a range of different fear/anxiety levels were childbirth education at the hospital (2 hours), prenatal Hatha yoga (8 weeks), and an 8-week prenatal education course (16 hours).

CONCLUSIONS

Findings from this review can inform the development of treatment approaches to support pregnant women with PSA/FoB.

Definitions, measurements and prevalence of fear of childbirth: a systematic review

Background

Fear of Childbirth (FOC) is a common problem affecting women’s health and wellbeing, and a common reason for requesting caesarean section. The aims of this review were to summarise published research on prevalence of FOC in childbearing women and how it is defined and measured during pregnancy and postpartum, and to search for useful measures of FOC, for research as well as for clinical settings.

Methods

Five bibliographic databases in March 2015 were searched for published research on FOC, using a protocol agreed a priori. The quality of selected studies was assessed independently by pairs of authors. Prevalence data, definitions and methods of measurement were extracted independently from each included study by pairs of authors. Finally, some of the country rates were combined and compared.

Results

In total, 12,188 citations were identified and screened by title and abstract; 11,698 were excluded and full-text of 490 assessed for analysis. Of these, 466 were excluded leaving 24 papers included in the review, presenting prevalence of FOC from nine countries in Europe, Australia, Canada and the United States. Various definitions and measurements of FOC were used. The most frequently-used scale was the W-DEQ with various cut-off points describing moderate, severe/intense and extreme/phobic fear. Different 3-, 4-, and 5/6 point scales and visual analogue scales were also used. Country rates (as measured by seven studies using W-DEQ with ≥85 cut-off point) varied from 6.3 to 14.8%, a significant difference (chi-square = 104.44, d.f. = 6, p < 0.0001).

Conclusions

Rates of severe FOC, measured in the same way, varied in different countries. Reasons why FOC might differ are unknown, and further research is necessary. Future studies on FOC should use the W-DEQ tool with a cut-off point of ≥85, or a more thoroughly tested version of the FOBS scale, or a three-point scale measurement of FOC using a single question as ‘Are you afraid about the birth?’ In this way, valid comparisons in research can be made. Moreover, validation of a clinical tool that is more focussed on FOC alone, and easier than the longer W-DEQ, for women to fill in and clinicians to administer, is required.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1659-7) contains supplementary material, which is available to authorized users.

A cost effectiveness analysis of midwife psycho-education for fearful pregnant women - a health system perspective for the antenatal period

Background

Psycho-education can reduce childbirth fear and caesarean section numbers. This study determines the cost-effectiveness of a midwife-led psycho-education intervention for women fearful of birth.

Method

One thousand four hundred ten pregnant women in south-east Queensland, Australia were screened for childbirth fear (W-DEQ A ≥ 66). Women with high scores (n = 339) were randomised to the BELIEF Study (Birth Emotions and Looking to Improve Expectant Fear) to receive psycho-education (n = 170) at 24 and 34 weeks of pregnancy or to the control group (n = 169). Women in both groups were surveyed 6 weeks postpartum with total cost for health service use during pregnancy calculated. Logistic regression models assessed the odds ratio of having vaginal birth or caesarean section in the study groups.

Result

Of 339 women randomised, 184 (54%) women returned data at 6 weeks postpartum (Intervention Group n = 91; Control Group n = 93). Women receiving psycho-education had a higher likelihood of vaginal birth compared to controls (n = 60, 66% vs. n = 54, 58%; OR 2.34). Mean ‘treatment’ cost for women receiving psycho-education was AUS$72. Mean cost for health services excluding the cost of psycho-education, was less in the intervention group (AUS$1193 vs. AUS$1236), but not significant (p = 0.78). For every five women who received midwife counselling, one caesarean section was averted. The incremental healthcare cost to prevent one caesarean section using this intervention was AUS$145.

Conclusion

Costs of delivering midwife psycho-education to women with childbirth fear during pregnancy are offset by improved vaginal birth rates and reduction in caesarean section numbers.

Trial registration

Australian New Zealand Controlled Trials Registry ACTRN12612000526875, 17th May 2012 (retrospectively registered one week after enrolment of first participant).

The effect of an elective cesarean section on maternal request on peripartum anxiety and depression in women with childbirth fear: a systematic review

BACKGROUND

Obstetricians are often reluctant to grant requests for an elective cesarean section (ECS) due to childbirth fear. To date, it is unknown if an ECS on request improves mental well-being in the mother in the peripartum period and if possible beneficial effects on anxiety and depression could outweigh the increased risk of complications associated with a surgical delivery. A systematic review was conducted to explore the effect of ECS on request on peripartum anxiety and depression.

METHODS

We searched on PubMed, PsychoInfo and Embase. Studies were included with primary data on anxiety and/or depression postpartum in women with childbirth fear who had requested an ECS. After full-text evaluation of 65 papers and quality analysis of four papers, three papers were included. Of one paper additional and yet unpublished data were provided. Studies varied in outcome measures, hence no meta-analysis was performed.

RESULTS

Women who requested an ECS had higher antepartum depression and anxiety levels but no different postpartum depression levels than women who delivered vaginally. One study of good quality examined the effect of vaginal delivery in women preferring ECS: These women had significantly higher symptom levels of post-traumatic stress disorder (PTSD) and depression than women with normal vaginal delivery.

CONCLUSIONS

The prospect of an ECS does not lower antepartum anxiety and/or depression levels in women requesting an ECS. If women resolutely persist in wishing an ECS despite adequate counselling and/or psychiatric treatment, the risk of developing depressive and PTSD symptoms in case of vaginal delivery should be taken into account, and an ECS may be considered as a valid alternative.

A randomized controlled study comparing internet-based cognitive behavioral therapy and counselling by standard care for fear of birth - A study protocol

Fear of birth is a concern that requires evidence based treatment. The aim of this study is to present the protocol of a randomized controlled multi-center trial to compare internet-based cognitive therapy with counseling as standard care for pregnant women reporting fear of birth. Participants will be recruited in mid-pregnancy. Women who score 60 or above on the Fear of Birth Scale will be offered to participate in this study. Data will be collected by questionnaires including validated instruments at baseline and follow-ups at gestational weeks 30 and 36, two months and one year after birth. The primary outcome will be level of fear of birth measured with the Fear of Birth Scale at 36 weeks of gestation. Secondary outcome measures are level of fear of birth at two months and one year after giving birth, preferences for mode of birth, requests for elective cesarean section, compliance and satisfaction with treatment and birth outcomes. A power calculation based on a 20% reduction of fear implies that approximately 200 will be included in the trial. The study outlined in this protocol will be the first randomized controlled trial comparing internet-based cognitive therapy with counseling for women reporting fear of birth. An effective treatment may result in better overall health for women with fear of birth and a reduction in cesarean sections for non-medical reasons. Evidence regarding treatment options of fear of birth will also provide a greater choice for women.

Giving birth: Expectations of first time mothers in Switzerland at the mid point of pregnancy

PROBLEM AND BACKGROUND

Despite a generally affluent society, the caesarean section rate in Switzerland has steadily climbed in recent years from 22.9% in 1998 to 33.7% in 2014. Speculation by the media has prompted political questions as to the reasons. However, there is no clear evidence as to why the Swiss rate should be so high especially in comparison with neighbouring countries.

AIM

To describe the emerging expectations of giving birth of healthy primigravid women in the early second semester of pregnancy in four Swiss cantons.

METHODS

Qualitative individual interviews with 58 healthy primigravid women, were audio recorded, transcribed and subjected to thematic analysis. Recruitment took place through public and private hospitals, birth centres, obstetricians and independent midwives. The main ethical issues were informed consent, autonomy, confidentiality and anonymity.

FINDINGS

The three main themes identified were taking or avoiding decisions, experiencing a continuum of emotions and planning the care.

DISCUSSION

Being pregnant was part of a project women had mapped out for their lives. Only three women in our sample expressed a wish for a caesarean section. One of the strongest emotions was that of fear but in contrast some participants expressed faith that their bodies would cope with the experience.

CONCLUSION

Bringing together the three languages and cultures produced a truly "Swiss" study showing contrasts between a matter of fact approach to pregnancy and the concept of fear. Such a contrast is worthy of further and deeper exploration by a multi-disciplinary research team.

Psychological perspectives on fear of childbirth

The objective of this narrative review was to examine the literature on fear of childbirth from a psychological perspective, addressing the specificity of childbirth fear, the pathways of fear acquisition, and the physiological, cognitive and behavioral aspects of fear. Systematic procedures for literature search, inclusion and exclusion left 86 original research papers for analysis. Findings summarize the body of knowledge for each area of interest, as well as the number of studies addressing each theme. Overall, few studies adopt a clear-cut psychological perspective, leaving the psychological mechanisms of childbirth fear largely unexplored. Although methodological limitations make conclusions difficult, results give a hint of etiological diversity and possible psychological mechanisms commonly described as transdiagnostic features in anxiety. Systematic investigations of psychological mechanisms, longitudinal studies exploring possible vicious circles of fear, and studies comparing psychological characteristics within the group of women fearing childbirth are identified as research areas of high priority.

Taking the matter into one's own hands - Women's experiences of unassisted homebirths in Sweden

OBJECTIVE

There are no national guidelines or financial support for planned homebirths in Sweden. Some women choose to give birth at home without the assistance of a midwife. The objective of this study was to describe eight women's experience of unassisted planned homebirth in Sweden.

DESIGN

Women who had the experience of an unassisted planned home birth were interviewed. The material was analysed using a phenomenological approach.

RESULTS

The essential meaning of the phenomenon giving birth at home without the assistance of a midwife is understood as a conflict between, on one hand, inner responsibility, power and control and on the other hand insecurity in relation to the outside, to other people and to the social system. A wish to be cared for by a midwife is in conflict with the fear of not maintaining integrity and respect in this precious moment of birth.

CONCLUSION

Some women may be more sensitive to attitudes and activities that are routinely performed during pregnancy and childbirth and therefore choose not to turn to any representatives of the medical system. The challenge should be to provide safe care to all women so that assistance from a midwife becomes a reality in all settings.

Pregnant women's preference for cesarean section and subsequent mode of birth - a six-country cohort study

INTRODUCTION

The rate of cesarean section (CS) for non-medical reasons has risen and it is a concern for health care. Women's preferences may vary across countries for psychosocial or obstetric reasons.

METHODS

A prospective cohort study of 6549 women in routine antenatal care giving birth in Belgium, Iceland, Denmark, Estonia, Norway or Sweden. Preference for mode of birth was self-reported in mid-pregnancy. Birth outcome data were collected from hospital records.

RESULTS

A CS was preferred by 3.5% of primiparous women and 8.7% of the multiparous women. Preference for CS was associated with severe fear of childbirth (FOC), with a negative birth experience in multiparous women and with depressive symptoms in the primiparous. Women were somewhat more prone to prefer a cesarean in Iceland, odd ratio (OR) 1.70 (1.02-2.83), adjusted for age, education, depression, FOC, history of abuse, previous cesarean and negative birth experience. Out of the 404 women who preferred CS during pregnancy, 286 (70.8%) delivered by CS, mostly for a medical indication. A total of 9% of the cesareans in the cohort had a non-medical indication only.

CONCLUSIONS

Women's preference for CS often seems to be due to health concerns. Both medical and psychological factors need to be addressed in antenatal counseling. Obstetricians need to convey accurately to women the risks and benefits of CS in her specific case. Maternity professionals should identify and explore psychosocial reasons for women's preferences.

[Fear of childbirth among nulliparous women: Relations with pain during delivery, post-traumatic stress symptoms, and postpartum depressive symptoms]

OBJECTIVE

Fear of childbirth is common in women who are pregnant with their first child and is associated with important consequences such as abortions and miscarriages. Twenty percent of nulliparous women seem to exhibit a mild or moderate fear, while 6% present an excessive and irrational fear known as tocophobia. Tocophobia is suggested to be associated with many negative consequences such as postpartum depression (PPD) and Post-traumatic stress (PTS). However, there is little empirical evidence to support these relationships. Recently, Fairbrother and Woody (2007) did not observe a link between the fear of childbirth and symptoms of PPD and PTS in nulliparous women. Some results, near the significance level, could be explained by a lack of statistical power. The present study focused on the link between the fear of childbirth and the process of delivery, the perception of pain, PPD and PTS. More specifically, it aimed to test three hypotheses: (i) fear of childbirth will be linked to the process of delivery, especially regarding the perception of pain, the use of anaesthesia and the use of Caesarean section; (ii) a high level of fear of childbirth will be associated with more negative postpartum consequences (namely PPD/PTS symptoms); (iii) the process of delivery and pain will also be related to post-delivery symptoms. Mediation effects were tested.

METHOD

Data from a longitudinal study were used to meet the hypotheses. A total of 176 nulliparous pregnant women responded to questionnaires at two time measurements (during pregnancy and at 5weeks postpartum).

RESULTS

Fear of childbirth is related to the perception of pain at birth among women delivering vaginally, in the absence of anaesthesia. It is also linked to symptoms of PPD and PTS, regardless of whether or not anaesthesia was used. Fear of childbirth also appears to be strongly associated to symptoms of PTS in women who have experienced an unplanned caesarean section. Thus, symptoms of postpartum PTS could play a mediating role in the link between fear of childbirth and PPD.

CONCLUSIONS

These results support the relevance of taking into account the fear of childbirth and perception of pain in connection with symptoms of PTS and PPD in nulliparous women. The unplanned caesarean section (including emergency caesarean) also appears to be important in the study of the relationship between fear and symptoms of PTS. Fear of childbirth could render the experience of childbearing more negative and predispose to PTS and PPD. Enabling psychological vulnerabilities could also be an interesting avenue for understanding these links. Limitations are discussed.

Swedish women's interest in models of midwifery care - Time to consider the system? A prospective longitudinal survey

BACKGROUND

Sweden has an international reputation for offering high quality maternity care, although models that provide continuity of care are rare. The aim was to explore women's interest in models of care such as continuity with the same midwife, homebirth and birth center care.

METHODS

A prospective longitudinal survey where 758 women's interest in models such as having the same midwife throughout antenatal, intrapartum and postpartum care, homebirth with a known midwife, and birth center care were investigated.

RESULTS

Approximately 50% wanted continuity of care with the same midwife throughout pregnancy, birth and the postpartum period. Few participants were interested in birth center care or home birth. Fear of giving birth was associated with a preference for continuity with midwife.

CONCLUSIONS

Continuity with the same midwife could be of certain importance to women with childbirth fear. Models that offer continuity of care with one or two midwives are safe, cost-effective and enhance the chance of having a normal birth, a positive birth experience and possibly reduce fear of birth. The evidence is now overwhelming that all women should have maternity care delivered in this way.

Effects of a midwife psycho-education intervention to reduce childbirth fear on women's birth outcomes and postpartum psychological wellbeing

BACKGROUND

High levels of childbirth fear impact birth preparation, obstetric outcomes and emotional wellbeing for around one in five women living in developed countries. Higher rates of obstetric intervention and caesarean section (CS) are experienced in fearful women. The efficacy of interventions to reduce childbirth fear is unclear, with no previous randomised controlled trials reporting birth outcomes or postnatal psychological wellbeing following a midwife led intervention.

METHOD

Between May 2012 and June 2013 women in their second trimester of pregnancy were recruited. Women with a fear score ≥ 66 on the Wijma Delivery Expectancy / Experience Questionnaire (W-DEQ) were randomised to receive telephone psycho-education by a midwife, or usual maternity care. A two armed non-blinded parallel (1:1) multi-site randomised controlled trial with participants allocated in blocks of ten and stratified by hospital site and parity using an electronic centralised computer service. The outcomes of the RCT on obstetric outcomes, maternal psychological well-being, parenting confidence, birth satisfaction, and future birth preference were analysed by intention to treat and reported here.

RESULTS

1410 women were screened for high childbirth fear (W-DEQ ≥66). Three hundred and thirty-nine (n = 339) women were randomised (intervention n = 170; controls n = 169). One hundred and eighty-four women (54 %) returned data for final analysis at 6 weeks postpartum (intervention n = 91; controls n = 93). Compared to controls the intervention group had a clinically meaningful but not statistically significant reduction in overall caesarean section (34 % vs 42 %, p = 0.27) and emergency CS rates (18 % vs 25 %, p = 0.23). Fewer women in the intervention group preferred caesarean section for a future pregnancy (18 % vs 30 %, p = 0.04). All other obstetric variables remained similar. There were no differences in postnatal depression symptoms scores, parenting confidence, or satisfaction with maternity care between groups, but a lower incidence of flashbacks about their birth in the intervention group compared to controls (14 % vs 26 %, p = 0.05). Postnatally women who received psycho-education reported that the 'decision aid' helped reduce their fear (53 % vs 37 %, p = 0.02).

CONCLUSION

Following a brief antenatal midwife-led psycho-education intervention for childbirth fear women were less likely to experience distressing flashbacks of birth and preferred a normal birth in a future pregnancy. A reduction in overall CS rates was also found. Psycho-education for fearful women has clinical benefits for the current birth and expectations of future pregnancies.

TRIAL REGISTRATION

Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17th May 2012.