Terhi Saisto

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.

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.

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.

Women's and men's personal goals during the transition to parenthood.

To investigate how womens and mens personal goals change during the transition to parenthood, the authors studied 348 women (152 primiparous and 196 multiparous) and 277 of their partners at 3 times: early in pregnancy, 1 month before the birth, and 3 months afterward. At each measurement, participants completed the Personal Project Analysis questionnaire (B. R. Little, 1983). The results showed that during pregnancy women became more interested in goals related to childbirth, the childs health, and motherhood and less interested in achievement-related goals. After the birth women were more interested in family- and health-related issues. These changes were more substantial among the primiparous than among the multiparous mothers. Although the mens personal goals changed during the transition to parenthood, these changes were less substantial than those found among the women.

Goal reconstruction and depressive symptoms during the transition to motherhood : Evidence from two cross-lagged longitudinal studies

Two cross-lagged longitudinal studies were carried out to investigate the extent to which the adjustment of personal goals to match the particular stage-specific demands of the transition to motherhood has consequences for womens depressive symptoms. In Study 1. 348 women filled out a revised version of Littles (1983) Personal Project Analysis and a revised version of Becks Depression Inventory (A. T. Beck. C. H. Ward. M. Mendelsohn, L. Mock, & J. Erlaugh. 1961) 4 times: during early pregnancy, 1 month before childbirth, 3 months after childbirth. and 2 years after childbirth. In Study 2. 140 women who reported high levels of fear of childbirth filled out identical measures during early pregnancy, 1 month before childbirth, and 3 months after childbirth. The results showed that an increase in family-related goals during pregnancy and after the birth of the child predicted a decline in womens depressive symptoms. By contrast, an increase in self-focused goals predicted an increase in womens depressive symptoms.