Jennifer Ann Gamble

Pre- and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women.

AIM To investigate pre- and postpartum levels of childbirth fear in a cohort of childbearing women and explore the relationship to birth outcomes. BACKGROUND While results are mixed, there is evidence that fear of childbirth is associated with mode of birth. Limited theoretical work around childbirth fear has been undertaken with Australian women. DESIGN A prospective correlation design. Method. Women (n = 401) completed the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) version A at 36 weeks gestation, with 243 (61%) women also completing version B at six weeks postpartum. Scores were summarised with means and standard deviations. Content analysis of the free statements identified nine issues of concern. RESULTS Twenty-six per cent of pregnant women reported low levels of childbirth fear, 48% were moderately fearful and 26% were highly fearful. Fear decreased after birth for those women in the high antenatal fear group, however surgical intervention at birth (n = 238, anova, F(1,230) = 12.39, p = 0.001) and suspected fetal compromise (F(1,230) = 4.33, p = 0.039) increased levels of postpartum fear. Univariately, high antenatal fear was associated with emergency caesarean delivery (n = 324, Wald 5.05, p = 0.025) however after adjustment for nulliparity and fetal compromise the association disappeared. Australian-born women were more likely to report higher levels of fear and experience higher rates of caesarean section than participants of non-Australian origin. CONCLUSIONS Results support those from earlier studies in showing that nulliparous women experience more fear than parous women before birth and that there is no difference in levels of postpartum fear between these two groups. Fear levels were higher in Australian women when compared to a Swedish sample. RELEVANCE TO CLINICAL PRACTICE The results of this study add to our preliminary understanding of the phenomena of childbirth fear within an Australian context and are particularly useful in profiling women for whom secondary fear of childbirth is more likely to occur.

Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women

OBJECTIVES To investigate the prevalence of depression during pregnancy and postpartum period for Jordanian women and identify associated risk factors and maternity service delivery issues. DESIGN A prospective cross-sectional study. Participants were recruited during the last trimester of pregnancy, provided personal, social and obstetric information, and completed the Edinburgh Postnatal Depression Scale (EPDS), Depression Anxiety and Stress Scale (DASS-21), the Maternity Social Support Scale (MSSS), the Cambridge Worry Scale (CWS), Perceived Self-Efficacy Scale (PSES) and Perceived Knowledge Scale (PKS). All participants were contacted again at six-eight weeks and six months post partum to complete a telephone or face-to-face interview. The postnatal questionnaire included the EPDS, MSSS, and DASS-21. SETTING A teaching hospital and five health centres in Irbid city in northern Jordan. PARTICIPANTS Arabic speaking women (n = 353) between the ages of 18 and 45 years, in their last trimester of pregnancy, at low risk for obstetric complications and receiving antenatal care between November 2005 and August 2006. FINDINGS High rates of antenatal (19%) and postnatal depression (22%) were reported. A regression analysis revealed that stress, anxiety, financial problems, perceived lack of parenting knowledge, difficult relationship with the mother-in-law, unplanned pregnancy, and low self-efficacy were associated with antenatal depression. These seven factors accounted for 83% (r(2) = 0.834) of variance in the development of probable antenatal depression. At six-eight weeks post partum, a regression analysis revealed that antenatal depression, unplanned pregnancy, difficult relationship with mother-in-law, dissatisfaction with overall care, stress, lack of social support, giving birth to a female baby, feeling pressured to birth the baby quickly, and perceived low parenting knowledge were associated with postnatal depression. These nine variables accounted for 82% (r(2) = 0.819) of variance in the development of probable PND. Three intrapartum and postpartum variables associated with PND at six-eight weeks (postpartum haemorrhage, unhelpful doctors during labour and birth, and anxiety) were no longer associated with PND at six months. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Jordanian women need support to prepare for labour and birth. Postpartum emotional support and assessment of symptoms of depression needs to be incorporated into routine practice. The opportunity for open discussion along with increased awareness and clarification of common misconceptions about antenatal and postnatal depression are necessary. Quality assurance systems would help reduce the rate of invasive obstetric procedures, and give greater emphasis to emotional care provided to women during the perinatal period.

Prevalence of childbirth fear in an Australian sample of pregnant women

BackgroundChildbirth fear is reported to affect around 20% of women. However reporting on levels of symptom severity vary. Unlike Scandinavian countries, there has been limited focus on childbirth fear in Australia. The aim of this paper is to determine the prevalence of low, moderate, high and severe levels of childbirth fear in a large representative sample of pregnant women drawn from a large randomised controlled trial and identify demographic and obstetric characteristics associated with childbirth fear.MethodUsing a descriptive cross-sectional design, 1,410 women in their second trimester were recruited from one of three public hospitals in south-east Queensland. Participants were screened for childbirth fear using the Wijma Delivery Expectancy/Experience Questionnaire Version A (WDEQ-A). Associations of demographic and obstetric factors and levels of childbirth fear between nulliparous and multiparous women were investigated.ResultsPrevalence of childbirth fear was 24% overall, with 31.5% of nulliparous women reporting high levels of fear (score ≥66 on the WDEQ-A) compared to 18% of multiparous women. Childbirth fear was associated with paid employment, parity, and mode of last birth, with higher levels of fear in first time mothers (p < 0.001) and in women who had previously had an operative birth (p < 0.001).ConclusionPrevalence of childbirth fear in Australian women was comparable to international rates. Significant factors associated with childbirth fear were being in paid employment, and obstetric characteristics such as parity and birth mode in the previous pregnancy. First time mothers had higher levels of fear than women who had birthed before. A previous operative birth was fear provoking. Experiencing a previous normal birth was protective of childbirth fear.

A Randomized Controlled Trial of a Psycho-Education Intervention by Midwives in Reducing Childbirth Fear in Pregnant Women

Background Childbirth fear is associated with increased obstetric interventions and poor emotional and psychological health for women. The purpose of this study is to test an antenatal psycho-education intervention by midwives in reducing womens childbirth fear. Methods Women (n = 1,410) attending three hospitals in South East Queensland, Australia, were recruited into the BELIEF trial. Participants reporting high fear were randomly allocated to intervention (n = 170) or control (n = 169) groups. All women received a decision-aid booklet on childbirth choices. The telephone counseling intervention was offered at 24 and 34 weeks of pregnancy. The control group received usual care offered by public maternity services. Primary outcome was reduction in childbirth fear (WDEQ-A) from second trimester to 36 weeks’ gestation. Secondary outcomes were improved childbirth self-efficacy, and reduced decisional conflict and depressive symptoms. Demographic, obstetric & psychometric measures were administered at recruitment, and 36 weeks of pregnancy. Results There were significant differences between groups on postintervention scores for fear of birth (p < 0.001) and childbirth self-efficacy (p = 0.002). Decisional conflict and depressive symptoms reduced but were not significant. Conclusion Psycho-education by trained midwives was effective in reducing high childbirth fear levels and increasing childbirth confidence in pregnant women. Improving antenatal emotional well-being may have wider positive social and maternity care implications for optimal childbirth experiences.

Childbirth and criteria for traumatic events

OBJECTIVE for some women childbirth is physically and psychologically traumatic and meets Criterion A1 (threat) and A2 (intense emotional response) for Posttraumatic Stress Disorder of the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV).This study differentiates Criterion A1 and A2 to explore their individual relationship to prevalence rates for posttraumatic stress, each other, and associated factors for childbirth trauma. DESIGN AND SETTING women were recruited at three hospitals from October 2008 to October 2009. Questionnaires were completed at recruitment and at 14 days post partum. PARTICIPANTS women in the third trimester of pregnancy (n=890) were recruited by a research midwife while waiting for their antenatal clinic appointment. Participants were over 17 years of age, expected to give birth to a live infant, not undergoing psychological treatment, and able to complete questionnaires in English. FINDINGS this study found 14.3% of women met criteria for a traumatic childbirth. When the condition of A2 was removed, the prevalence rate doubled to 29.4%. Approximately half the women who perceived threat in childbirth did not have an intense negative emotional response. Predictors of finding childbirth traumatic were pre-existing psychiatric morbidity, being a first time mother and experiencing an emergency caesarean section. KEY CONCLUSIONS the fear response is an important diagnostic criterion for assessing psychologically traumatic childbirth. The identification of risk factors may inform maternity service delivery to prevent traumatic birth and postpartum approaches to care to address long-term negative consequences. IMPLICATIONS FOR PRACTICE prevention and treatment of traumatic childbirth are improved through knowledge of potential risk factors and understanding the womans subjective experience.

Level of burnout in a small population of Australian midwives

UNLABELLED The aim of the study was to describe the level of burnout in midwives working at a maternity unit in South East Queensland, Australia. METHOD A self-administered questionnaire was distributed to all registered midwives (N=110) working at the study site during November 2011. The questionnaire included a demographic survey and the Copenhagen Burnout Inventory. Fifty-eight (52.7%) staff completed the package. Data was entered into SPSS database version 19 and descriptive statistics were used to determine means, ranges and frequencies. RESULTS Almost 30% of the sample experienced moderate to high levels of burnout some 50% of participants scored moderate to high for personal burnout with a similar number scoring high for work-related burnout. In comparison, burnout related to working with clients was very low. Differences between participants were associated with years of experience, area of work and employment position (FT/PT, level of position and work area). Participants aged 35years or younger and with less than 10years midwifery experience scored highest on the personal and work-related domains whereas participants over 35years scored highest within the client-related domain. Midwives at level 1 (lowest pay group) scored highest for work-related burnout and client-related burnout. Midwives in more senior positions (level 2 and above) scored highest for personal burnout. CONCLUSION Personal and work-related burnout was high in this group of midwives while burnout related to caring for women was low. These results provide insight into the emotional health of midwives in one maternity unit. While more work is needed, strategies to decrease and/or prevent burnout may include clinical mentorship and reorganising models of maternity care to increase work satisfaction and autonomy and strengthen relationships between midwives and women.

Does the way maternity care is provided affect maternal and neonatal outcomes for young women? A review of the research literature

BACKGROUND Young pregnant women who continue a pregnancy are primarily from a socioeconomically deprived background. The risk factors associated with low socio-economic status may independently affect perinatal and neonatal morbidity to a greater extent than the young age of the woman. Young pregnant women are frequently sceptical about health care providers who they can perceive to be judgemental. This may lead to late booking for pregnancy care, attending few appointments, or not attending the health service for any antenatal care. QUESTION Does the way maternity care is provided affect maternal and neonatal outcomes for young women? METHOD A systematic search of the major health databases. RESULTS Nine research articles met the eligibility criteria: one randomised controlled trial, three prospective cohort studies, two comparative studies with concurrent controls, two comparative studies with historical controls, and one case series. DISCUSSION Providing young women with a non-standard model of maternity care has some beneficial and no known detrimental effects on childbirth outcomes. While there is a dearth of evidence on the effectiveness of a Midwifery Group Practice model of care for young women, there is strong evidence to suggest that a Group Antenatal Care model increases antenatal visit attendance and breastfeeding initiation, and decreases the risk of preterm birth. There is research to indicate that a Young Womens Clinic model may also increase antenatal visit attendance and decrease the incidence of preterm birth. CONCLUSION More well-designed and resourced midwifery models of care for young women should be implemented and rigorously researched.

Couple Relationship Education at the Transition to Parenthood: A Window of Opportunity to Reach High-Risk Couples

This study evaluated if the transition to parenthood is a window of opportunity to provide couple relationship education (CRE) to new parents at high risk for future relationship problems. Fifty-three percent of eligible couples approached agreed to participate in CRE and of these 80% had not previously accessed CRE. Couples were a broad representative of Australian couples having their first child, but minority couples were underrepresented. A third of couples had three or more risk factors for future relationship distress (e.g., cohabiting, interpartner violence, elevated psychological distress, unplanned pregnancy). Low education was the only risk factor that predicted drop out. The transition to parenthood is a window of opportunity to recruit certain types of high-risk couples to CRE.

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.

Sources, responses and moderators of childbirth fear in Australian women: A qualitative investigation

BACKGROUND around 20% of women suffer childbirth fear causing them significant distress and often leading to requests for caesarean section. In Sweden, fearful pregnant women are offered counselling; however, in Australia, no dedicated service caters for the specific needs of these women. Indeed scant research has been conducted in Australia and little is known about womens concerns and if these align to those reported in the international literature. AIM to describe the sources, responses and moderators of childbirth fear in a group of pregnant women assessed as having high levels of childbirth fear. METHOD comparative analysis was used to identify common concepts and generate themes that represented womens perspectives of childbirth fear. Data consisted of 43 tape recorded telephone conversations with highly fearful pregnant women who were participating in a large randomised controlled trial known as BELIEF (Birth Emotions, Looking to Improve Expectant Fear). FINDINGS womens fears were conceptualised into three themes: fear stimuli; fear responses; and fear moderators. Lack of confidence to birth, fear of the unknown, internalising other womens negative stories, perineal tearing and labour pain were common concerns for first time mothers. For multiparous women, not having had personal feelings resolved following their previous birth and negative experiences of last birth influenced current expectations for their upcoming birth. Themes common to both groups were: unmet information and support needs, feelings of loss of control and lack of input in to decision-making. Some women however, chose to avoid birth planning in order to cope during pregnancy. CONCLUSION Australian women had similar childbirth concerns to those reported in the international literature. However unique to this study was finding two opposing discourses; one of preoccupation with negative events and the other; avoidance of planning for labour and birth. Provision of woman centred maternity models that minimise obstetric intervention, offer personalised conversations following birth, and are sensitive to identifying; listening and assisting women to modify their fears in early pregnancy are required to promote positive anticipation and preparation for birth.