Erja Halmesmäki

Fear of childbirth: a neglected dilemma

Severe fear of childbirth complicates 6% to 10% of parturients and is manifested as nightmares, physical complaints and difficulties in concentrating on work or on family activities. Very often fear of childbirth leads to request for an elective cesarean section (CS). In Finland, Sweden, and the United Kingdom, fear of childbirth or maternal request is the reason for about 7–22% of CS births. Fear of childbirth is as common in nulliparous as in parous women. Fear of labor pain is strongly associated with the fear of pain in general, and a previous complicated childbirth or inadequate pain relief are the most common reasons for requesting a CS among parous women. Previous psychological morbidity and a great number of daily stressors expose a woman to a great risk of fear of childbirth. Fear of childbirth is not an isolated problem but associated with the womans personal characteristics, mainly general anxiety, low self‐esteem, and depression, and dissatisfaction with their partnership, and lack of support. Also the partners of women with fear have a certain pattern of low psychological well‐being, resulting in low life‐satisfaction, dissatisfaction with partnerships, and depression. A vivid debate about the womans right to choose the mode of delivery is going on in obstetric literature, but discussion on the reasons for women to request a CS, or on the possibilities to help them overcome the fear of vaginal childbirth is scanty. Preliminary Swedish and Finnish reports demonstrated the results of treatment during pregnancy, when more than half of the women withdrew their request after being able to discuss their anxiety and fear, and vaginal deliveries after treatment were successful.

Fear of childbirth according to parity, gestational age, and obstetric history

Objective  To examine fear of childbirth according to parity, gestational age, and obstetric history.

Emotional, physical, and sexual abuse in patients visiting gynaecology clinics : a Nordic cross-sectional study

BACKGROUND Abuse against women causes much suffering for individuals and is a major concern for society. We aimed to estimate the prevalence of three types of abuse in patients visiting gynaecology clinics in five Nordic countries, and to assess the frequency with which gynaecologists identify abuse victims. METHODS We did a cross-sectional, multicentre study of women attending five departments of gynaecology in Denmark, Finland, Iceland, Norway, and Sweden. We recruited 4729 patients; 3641 (77%) responded and were included in the study. Participants completed a postal questionnaire (norvold abuse questionnaire) confidentially. Primary outcome measures were prevalences of emotional, physical, and sexual abuse, and whether abused patients had told their gynaecologist about these experiences. We assessed differences between countries with Pearsons chi(2) test. FINDINGS The ranges across the five countries of lifetime prevalence were 38-66% for physical abuse, 19-37% for emotional abuse, and 17-33% for sexual abuse. Not all abused women reported current ill-effects from the abusive experience. Most women (92-98%) had not talked to their gynaecologist about their experiences of abuse at their latest clinic visit. INTERPRETATION Despite prevalences of emotional, physical, and sexual abuse being high in patients visiting gynaecology clinics in the Nordic countries, most victims of abuse are not identified by their gynaecologists. This lack of discussion might increase the risk of abused patients not being treated according to their needs. Gynaecologists should always consider asking their patients about abuse.

A randomized controlled trial of intervention in fear of childbirth

OBJECTIVE To compare intensive and conventional therapy for severe fear of childbirth. METHODS In Finland, 176 women who had fear of childbirth were randomly assigned at the 26th gestational week to have either intensive therapy (mean 3.8 ± 1.0 sessions with obstetrician and one with midwife) or conventional therapy (mean 2.0 ± 0.6 sessions), with follow‐up 3 months postpartum. Pregnancy‐related anxiety and concerns, satisfaction with childbirth, and puerperal depression were assessed with specific questionnaires. Power analysis, based on previous studies, showed that 74 women per group were necessary to show a 50% reduction in cesarean rates. RESULTS Birth‐related concerns decreased in the intensive therapy group but increased in the conventional therapy group (linear interaction between the group and birth‐concerns P = .022). Labor was shorter in the intensive therapy group (mean ± standard deviation 6.8 ± 3.8 hours) compared with the conventional group (8.5 ± 4.8 hours, P = .039). After intervention, 62% of those originally requesting a cesarean (n = 117) chose to deliver vaginally, equally in both groups. Cesarean was more frequent for those who refused to fill in the questionnaires than for those who completed them (57% compared with 27%, P = .001). In the log‐linear model, parous women who had conventional therapy and refused to fill in the questionnaires chose a cesarean more often than expected (standardized residual 2.54, P = .011). There were no differences between groups in satisfaction with childbirth or in puerperal depression. CONCLUSION Both kinds of therapy reduced unnecessary cesareans, more so in nulliparous and well‐motivated women. With intensive therapy, pregnancy‐ and birth‐related anxiety and concerns were reduced, and labors were shorter.

Psychosocial characteristics of women and their partners fearing vaginal childbirth.

Objectives To examine the personal characteristics and socio‐economic background of women and their partners fearing vaginal childbirth.

Amniotic fluid--soluble vascular endothelial growth factor receptor-1 in preeclampsia.

Objective To measure the levels of the soluble receptor for the potent angiogenic agent vascular endothelial growth factor (VEGF) in amniotic fluid (AF) in healthy and complicated pregnancies, and compare them with levels of erythropoietin, another factor upregulated by hypoxia. Methods We assessed amniotic fluid from the second (n = 35, gestational weeks 14–19) and third (n = 29) trimesters of healthy women, and from the third trimesters of preeclamptic (n = 22) and diabetic women with (n = 11) or without preeclampsia (n = 34) and from women with fetal growth restriction (FGR) (n = 14) for soluble VEGF receptor-1 (VEGFR-1) by enzyme-linked immunosorbent assay. Results In early normal pregnancy, AF-soluble VEGFR-1 levels were higher (median 22 ng/mL, range 2.3–29.5 ng/mL) than in the third trimester (median 13 ng/mL, range 0.5–32 ng/mL; P < .05). In preeclamptic women during the third trimester, levels were higher (median 20 ng/mL, range 10.5–37 ng/mL; P < .05) than healthy controls. The lowest third-trimester levels were in diabetic women (median 11 ng/mL, range 0.5–27 ng/mL). In women with preeclampsia and diabetes, AF-soluble VEGFR-1 levels remained lower (median 13, range 6–32 ng/mL; P < .05) than in women with preeclampsia alone. Amniotic fluid levels of soluble VEGFR-1 in women with FGR (median 19.5 ng/mL, range 5–40 ng/mL) did not statistically differ from those of controls. The AF levels of soluble VEGFR-1 did not correlate with those of erythropoietin. Soluble VEGFR-1 was clearly detectable (median 14 ng/mL, range 9–22 ng/mL) in culture media from placental biopsies (n = 20). Conclusion Preeclampsia is associated with increased levels of soluble VEGFR-1, which are independent of erythropoietin, another hypoxia-inducible factor.

Factors associated with fear of delivery in second pregnancies

OBJECTIVE To identify factors associated with fear of childbirth during and after first labor. METHODS We analyzed first deliveries of 100 primiparas who reported severe fear of vaginal childbirth during their second pregnancies and 200 age- and parity-matched controls who reported no later fear of delivery. The main outcome measures were previous miscarriages, participation in birth-education classes, support during labor, length of first delivery, pain relief, obstetric complications, welfare of the newborn, and time between deliveries. RESULTS The prevalence of emergency cesarean (adjusted odds ratio [OR] 26.9, confidence interval [CI] 11.9, 61.1) and vacuum extraction (adjusted OR 4.5, CI 2.2, 9.3) during first delivery was much higher in subjects than controls. Labor lasted longer in cases than in controls during the first (10.5 hours versus 7.8 hours, P = .016) and second stages (62 minutes versus 47 minutes, P = .002). They received epidural analgesia more often, but its timing and the amount used were not different between groups. Of the group with fear, 44% could not define any specific cause for fear and regarded the entire delivery as frightening. CONCLUSION Emergency cesarean and vacuum extraction during first deliveries were associated with secondary fear of delivery. Emergency obstetric procedures cannot be avoided, so prevention of fear might require more education on causes and consequences of cesarean or vacuum extraction, eg, in birth classes and at postpartum visits.

Psychosocial predictors of disappointment with delivery and puerperal depression. A longitudinal study.

Background. To examine the extent to which personality characteristics, depression, fear and anxiety about pregnancy and delivery, and socio‐economic background, predict disappointment with delivery and the risk of puerperal depression.

Therapeutic group psychoeducation and relaxation in treating fear of childbirth

Background. The increase in the numbers of women fearing childbirth and requesting cesarean sections call for new forms of antenatal treatment. Methods. Finnish nulliparous women experiencing severe fear of childbirth (experimental group, n = 102) attended 5 group sessions with a psychologist, once together with a midwife, during the third trimester. One session was held 3 months after the delivery. Each session consisted of a discussion of fear and feelings towards the impending birth and parenthood in a psychotherapeutic atmosphere and of relaxation exercises focused on an imaginary childbirth. The results were compared with those of 85 women treated for fear of childbirth by 2 appointments with an obstetrician (conventional treatment). Results. Before the sessions, among the women in the experimental group, scored fear of childbirth, on a scale of one to ten, was 6.9±2.0 (SD), which is similar to the score of those receiving conventional treatment (6.0±1.6). After the sessions, 84 women in the experimental group (82.4%) and 57 in the conventional treatment group (67.1%) chose to have a vaginal delivery (p = 0.02). The women in the experimental treatment group rated the helpfulness of the sessions 8.5±1.6 on a scale where 10 was maximum help and 1 no help at all, and mentioned “sharing their feelings” twice as often as “receiving information” as the most helpful factor in relieving fear. Conclusions. Group psychoeducation and relaxation exercises were well received and rated as very helpful. More cesarean section requests were withdrawn than in the comparison group and in previous studies.

Obstetric outcome after intervention for severe fear of childbirth in nulliparous women – randomised trial

Objective  To compare the numbers of vaginal deliveries and delivery satisfaction among women with fear of childbirth randomised to either psychoeducation or conventional surveillance during pregnancy.