Helen Haines

Cross-cultural comparison of levels of childbirth-related fear in an Australian and Swedish sample

BACKGROUND research, conducted predominately in Scandinavian countries, suggests that a substantial number of women experience high levels of fear concerning childbirth which can impact on birth outcomes, the mother-infant relationship and the ongoing mental health of the mother. The prevalence of childbirth-related fear (CBRF) is not well known outside of the Nordic nations. This study aimed to examine the prevalence of CBRF in two rural populations (Sweden and Australia) and to pilot a short, easy-to-administer measurement tool. METHODS a questionnaire assessing a range of childbirth-related issues was administered to women in the first trimester across two rural populations in Sweden (n = 386) and Australia (n = 123). CBRF was measured using the Fear of Birth Scale (FOBS) a two-item visual analogue scale. FINDINGS close to 30% of women from the Australian and Swedish samples reported elevated levels of CBRF in the first trimester. A previous negative birth experience and less than positive attitudes to their current pregnancy and birth were predictive of high levels of fear. Swedish women with high levels of fear indicated a preference for caesarean section as the mode of birth in this pregnancy. A higher proportion (19%) of Australian women indicated that they would prefer an elective caesarean section, compared with only 8.8% of the Swedish sample; however, this was not related to high levels of fear. Preference for caesarean section was related to CBRF in the Swedish sample but not in the Australian sample. CONCLUSION the high proportion of women identified with CBRF suggests a need for monitoring of women during pregnancy, particularly those with a previous negative birth experience. The FOBS developed for this study could be used as a screening tool to identify women who require further investigation. Further cross-cultural research is needed to explore the role of fear in womens preference for caesarean section.

The influence of women’s fear, attitudes and beliefs of childbirth on mode and experience of birth

BackgroundWomen’s fears and attitudes to childbirth may influence the maternity care they receive and the outcomes of birth. This study aimed to develop profiles of women according to their attitudes regarding birth and their levels of childbirth related fear. The association of these profiles with mode and outcomes of birth was explored.MethodsProspective longitudinal cohort design with self report questionnaires containing a set of attitudinal statements regarding birth (Birth Attitudes Profile Scale) and a fear of birth scale (FOBS). Pregnant women responded at 18-20 weeks gestation and two months after birth from a regional area of Sweden (n = 386) and a regional area of Australia (n = 123). Cluster analysis was used to identify a set of profiles. Odds ratios (95% CI) were calculated, comparing cluster membership for country of care, pregnancy characteristics, birth experience and outcomes.ResultsThree clusters were identified – ‘Self determiners’ (clear attitudes about birth including seeing it as a natural process and no childbirth fear), ‘Take it as it comes’ (no fear of birth and low levels of agreement with any of the attitude statements) and ‘Fearful’ (afraid of birth, with concerns for the personal impact of birth including pain and control, safety concerns and low levels of agreement with attitudes relating to women’s freedom of choice or birth as a natural process). At 18 -20 weeks gestation, when compared to the ‘Self determiners’, women in the ‘Fearful’ cluster were more likely to: prefer a caesarean (OR = 3.3 CI: 1.6-6.8), hold less than positive feelings about being pregnant (OR = 3.6 CI: 1.4-9.0), report less than positive feelings about the approaching birth (OR = 7.2 CI: 4.4-12.0) and less than positive feelings about the first weeks with a newborn (OR = 2.0 CI 1.2-3.6). At two months post partum the ‘Fearful’ cluster had a greater likelihood of having had an elective caesarean (OR = 5.4 CI 2.1-14.2); they were more likely to have had an epidural if they laboured (OR = 1.9 CI 1.1-3.2) and to experience their labour pain as more intense than women in the other clusters. The ‘Fearful’ cluster were more likely to report a negative experience of birth (OR = 1.7 CI 1.02- 2.9). The ‘Take it as it comes’ cluster had a higher likelihood of an elective caesarean (OR 3.0 CI 1.1-8.0).ConclusionsIn this study three clusters of women were identified. Belonging to the ‘Fearful’ cluster had a negative effect on women’s emotional health during pregnancy and increased the likelihood of a negative birth experience. Both women in the ‘Take it as it comes’ and the ‘Fearful’ cluster had higher odds of having an elective caesarean compared to women in the ‘Self determiners’. Understanding women’s attitudes and level of fear may help midwives and doctors to tailor their interactions with women.

Childbirth fear in expectant fathers: Findings from a regional Swedish cohort study

OBJECTIVE to investigate the prevalence of childbirth related fear in Swedish fathers and associated factors. DESIGN a regional cohort study. Data was collected by a questionnaire. SETTING three hospitals in the middle-north part of Sweden PARTICIPANTS 1047 expectant fathers recruited in mid-pregnancy during one year (2007) who completed the Fear of Birth Scale (FOBS). MEASUREMENTS prevalence of childbirth fear and associated factors. Crude and adjusted odds ratios were calculated between men who scored 50 and above (childbirth fear) and those that did not (no fear). Logistic regression analysis was used to assess which factors contributed most to childbirth fear in fathers. FINDINGS the prevalence of childbirth fear in men was 13.6%. Factors associated with childbirth related fear were as follows: Less positive feelings about the approaching birth (OR 3.4; 2.2-5.2), country of birth other than Sweden (OR 2.8; 1.3-6.1), a preference for a caesarean birth (OR 2.1; 1.7-4.1), childbirth thoughts in mid-pregnancy (OR 1.9; 1.1-2.0) and expecting the first baby (OR 1.8; 1.2-2.6). KEY CONCLUSIONS high levels of fear were associated with first time fathers and being a non-native to Sweden. Men with fear were more likely to experience pregnancy and the coming birth as a negative event. These men were also more likely to identify caesarean section as their preferred mode of birth. IMPLICATIONS FOR PRACTICE engaging expectant fathers in antenatal conversations about their experiences of pregnancy and feelings about birth provides health-care professionals with an opportunity to address childbirth fear, share relevant information and promote birth as a normal but significant life event.

Identifying women who are afraid of giving birth: A comparison of the fear of birth scale with the WDEQ-A in a large Australian cohort

BACKGROUND The WDEQ-A is the most widely used measure of childbirth fear in pregnant women; however there is increasing discussion in the literature that simpler, more culturally transferrable tools may offer a better solution to identifying fearful women in clinical practice. AIM To compare the two item Fear of Birth Scale (FOBS) with the 33 item WDEQ-A in a large cohort of Australian pregnant women. METHOD Self-report questionnaires during second trimester including Wijma Delivery Expectancy Questionnaire (WDEQ-A) and Fear of Birth Scale (FOBS). Correlation of FOBS and WDEQ-A was tested using Spearmans correlation coefficients. Receiver operating characteristic (ROC) curve assessed the sensitivity and specificity of possible cut-points on the FOBS against WDEQ-A cut-point of ≥85. Sensitivity, specificity, positive and negative predictive values were determined. Fearful and non-fearful women as classified by both instruments were compared for differences in demographic, psycho-social and obstetric characteristics. RESULTS 1410 women participated. The correlation between the instruments was strong (Spearmans Rho = 0.66, p < 0.001). The area under the ROC was 0.89 indicating high sensitivity with a FOBS cut-point of 54. Sensitivity was 89%, specificity 79% and Youden index 0.68. Positive predictive value was 85% and negative predictive value 79%. Both instruments identified high fear as significantly associated with first time mothers, previous emergency caesarean and women with self-reported anxiety and/or depression. Additionally FOBS identified a significant association between fearful women and preference for caesarean. CONCLUSION This study supports the use of the FOBS in clinical practice to identify childbirth fear in pregnant women.

Higher prevalence of childbirth related fear in foreign born pregnant women - Findings from a community sample in Sweden

OBJECTIVE to investigate the prevalence of childbirth related fear (CBRF) in early pregnancy among both Swedish born and foreign born women living in Sweden. DESIGN a cross sectional prevalence study. Data was collected by a questionnaire, which was available in Swedish and eight other languages. SETTING a university hospital in the middle of Sweden. PARTICIPANTS the recruitment took place during a two month period where the participating women completed the Fear of Birth Scale (FOBS) in mid-pregnancy. MEASUREMENTS prevalence of CBRF, the cut-point of 60 and above. Odds ratios with a 95% confidence interval were calculated between women born in Sweden and women born in a foreign country. Stratified analyses were also performed separately for Swedish born and foreign born women. FINDINGS in total 606 women completed the survey, 78% were born in Sweden and 22% were born in a foreign country. About 22% of the total sample scored 60 or more on the FOBS-scale. Almost 18% (n=85) of the women born in Sweden reported CBRF whereas 37 % (n=49) of the foreign born women reported CBRF. Being born outside Sweden (OR 2.7; CI 1.7-4.0) and expecting the first baby (OR 1.9; CI 1.3-2.8) were associated with CBRF. There were no differences in age, civil status or level of education between women with or without FOBS≥60. However, a stratified analysis showed that primiparas born in a foreign country (OR 3.8; CI 1.8-8.0) were more likely to score 60 or more on the FOBS-scale compared to multiparas born in a foreign country. KEY CONCLUSIONS childbirth related fear was almost three times as common among foreign born women when compared to Swedish women. Foreign born childbearing women are an extremely vulnerable group who need culturally sensitive and targeted support from caregivers. Further research is needed to clearly identify the components of women׳s childbirth related fear in various ethnic groups.

Women's satisfaction with antenatal care: comparing women in Sweden and Australia.

BACKGROUND Satisfaction with antenatal care could differ depending on the organisation and the context of care. AIM To compare antenatal care in Australia and Sweden, to identify deficiencies in the content of antenatal care and what aspects contributed most in dissatisfaction with antenatal care. METHODS A longitudinal survey of 123 Australian and 386 Swedish women recruited during one year in regional hospitals in Sweden and Australia. Data collected by three questionnaires. RESULTS Women in Australia had more antenatal visits, less continuity of midwife caregiver but were more satisfied with antenatal education and the emotional aspects of antenatal care. Although the overall satisfaction was high, deficiencies were found in more than half of the studied variables in the content of care. Women in Sweden were more dissatisfied with information about labour and birth (OR 3.1; 1.8-5.3) and information about the time following birth (OR 3.8; 2.2-6.3), but more satisfied with the involvement of the father (OR 0.3; 0.2-0.6). Factors that contributed most to dissatisfaction with antenatal care overall were deficiency in information about pregnancy related issues (OR 3.4; 1.3-8.7) and not being taken seriously by the midwife (OR 4.1; 1.6-10.1). CONCLUSION Satisfaction with antenatal care was high in both groups of women. Australian women were more satisfied than the Swedish women with the emotional aspects of care. Deficiencies were found in more than half of the variables measured relating to the specific aspects of care. Lack of information and not being treated seriously were important factors for not being satisfied.

Psychometric evaluation and refinement of the Prenatal Attachment Inventory

Objective: To explore the underlying structure of the Prenatal Attachment Inventory (PAI) and to assess the psychometric properties of the subscales. Background: The establishment of the mother–fetus relationship is an important developmental task for successful adaption to pregnancy, with implications for the well-being of mother and child. The PAI was developed to measure the relationship between a women and her fetus. Although originally developed as a single dimension, other researchers have suggested alternative factor structures. Methods: A self-report questionnaire, including the PAI, was administered to 775 Swedish women in late pregnancy. Psychometric assessment of the PAI was undertaken using exploratory (EFA) and confirmatory factor analysis (CFA), and Rasch analysis. Results: EFA indicated a three-factor solution, which was confirmed by CFA. The previously reported single-factor and five-factor solutions were not supported. Rasch analysis was used to form three 6-item PAI-Revised subscales (Anticipation, Interaction, Differentiation). All subscales showed good overall fit to the Rasch model and good internal consistency. The three subscales were moderately intercorrelated, sharing between 23% and 42% of their variance, suggesting they should be used separately, pending further research concerning their unique predictive power. Conclusion: These results suggest that PAI-Revised is a psychometrically sound tool, suitable for use in research and clinical settings. It can be used to guide the identification, support, and follow-up of pregnant women with low attachment. The three subscales, although related, may tap different aspects of the attachment construct, with different antecedents and consequences for the well-being of mother and child.

Pregnant women's thoughts when assessing fear of birth on the Fear of Birth Scale

BACKGROUND Fear of childbirth is common during pregnancy but rarely assessed in clinical practice. The Fear of Birth Scale has been proposed as a valid measure suitable for assessing fear of birth in an antenatal clinical context. To make sure that the scale makes sense in relation to the known constructs of fear of birth, it is important to find out what women think when responding to the Fear of Birth Scale. AIM To report what women in mid-pregnancy think when assessing fear of birth on the Fear of Birth Scale. METHODS A qualitative design using semi-structured interviews with a think aloud technique was used. Thirty-one women were recruited in gestational week 17-20. Content analysis was conducted to describe the different dimensions of fear of birth. FINDINGS Worry was described as unspecific feelings and thoughts, often with a negative loading. Fear was described as a strong feeling connected to something specific. Furthermore, the women thought about aspects that influence their worries and fears and explained the strategies that helped them to cope with their fear of birth. CONCLUSION Women could clearly assess, describe, and discuss fear of birth using the Fear of Birth Scale. This supports the use of the Fear of Birth Scale in clinical settings as a starting point for further dialogue about womens fear of birth. The dialogue may identify womens need for information, treatment, and referral when necessary.

Rural Victorian Telestroke project.

Intravenous thrombolysis improves functional outcomes in acute ischaemic stroke. However, many rural stroke patients are denied thrombolysis because of a rural neurologist shortage. ‘Telestroke’ facilitates thrombolysis by providing remote access to neurologists via videoconferencing systems.

Maternal depressive symptoms have a negative impact on prenatal attachment – findings from a Swedish community sample

Objective: The objective of this study was to evaluate attachment and its association to obstetric and demographic factors as well as emotional well-being using a standard measure of prenatal attachment during pregnancy. Background: The strength of the mothers’ relationship with her baby has important implications in the postnatal period, influencing the relationship she develops with her child, and the quality of the care she provides. Methods: This was a population-based longitudinal survey comprising a consecutive sample from a one-year cohort in a Swedish county. In this study the three subscales of PAI-R (Prenatal Attachment Inventory – Revised) were used for evaluation of attachment. In total, 718 pregnant women participated in this study. Results: Women with elevated levels of depression (HADS-D > 8) recorded lower attachment scores across all three PAI-R subscales. Lack of perceived support from partner was associated with lower scores on Interaction. Lack of support from own mother and own father were also associated with lower scores on all subscales. Attachment was also associated with feelings about the approaching birth and about the first weeks with the newborn, with women who reported less than positive feelings recording lower scores on each of the PAI-R subscales. Conclusion: A focus on attachment during antenatal care and the use of PAI-R during pregnancy provides a means of identifying those women who show lower levels of attachment and possible emotional problems that may impact on emotional health and the birth process.