Fear of childbirth, postnatal post-traumatic stress disorder and midwifery care

Translation and Validation of the City Birth Trauma Scale With Lithuanian Postpartum Women: Findings and Initial Results

The childbirth experience and birth-related trauma are influenced by various factors, including country, healthcare system, a woman's history of traumatic experiences, and the study's design and instruments. This study aimed to validate the City Birth Trauma scale for Lithuanian women post-childbirth. Using a descriptive, cross-sectional survey with a nonprobability sample of 794 women who gave birth from 2020-2021, the study found good validity, reliability, and presented the prevalence of birth-related stress symptoms. A bifactor model, consisting of a general birth trauma factor and two specific factors for birth-related symptoms and general symptoms of PTSD, showed the best model fit. The Lithuanian version of the City Birth Trauma scale can be effectively used in research and clinical practice to identify birth-related trauma symptoms in women after giving birth.

The effect of respectful maternity care on the perception of traumatic birth among mothers in southern Türkiye

BACKGROUND

Respectful maternity care is a universal right for all reproductive women. The relationship between women and maternity care providers is crucial throughout pregnancy, birth, and postpartum. Qualitative studies suggest that care quality and interactions with healthcare professionals impact women more than medical interventions. This study examines the effect of respectful maternity care on the perception of traumatic birth.

METHODS

The study was conducted with 540 mothers who had a healthy birth in a public hospital in southern Türkiye between May and August 2024. The data collection process was carried out in two stages. In the first stage, mothers who completed the 24-h postpartum period filled out the Personal Information Form and the Women's Perception of Respectful Maternity Care Scale, and their contact information was obtained. In the second stage, one week after birth, the Birth-Related Trauma Perception Scale was completed through phone interviews with the mothers.

RESULTS

Mothers'perceptions of birth-related trauma and respectful maternal care were found to have significant relationships with many sociodemographic and obstetric variables (p < 0.05). The participants'mean respectful maternal care score and mean trauma perception score were 68.55 ± 9.30 and 120.80 ± 14.53, respectively. In addition, a high level of negative correlation was found between birth trauma and respectful maternal care (r = - 0.864; p < 0.001).

CONCLUSIONS

The study revealed that women exhibited a high perception of psychological trauma and a moderate perception of respectful maternity care. The findings indicate that sociodemographic and obstetric factors play a significant role in shaping women's experiences of both respectful care and birth trauma. Notably, a strong negative correlation was identified between respectful maternity care and the perception of birth trauma.

An integrative review of healthcare professionals' experiences in caring for women who have experienced psychological birth trauma or birth related Post Traumatic Stress Disorder

BACKGROUND

A significant proportion of women worldwide experience childbirth as a traumatic event, which may result in enduring consequences for themselves, their partners and their children. Healthcare professionals have a key role in supporting women with psychological birth trauma and birth related post-traumatic stress disorder through prevention, early detection and supportive practices but evidence indicates that these phenomena, are not recognised by practitioners.

DESIGN

This integrative review followed Whittemore and Knafl's five-stage framework as it facilitates the inclusion of different methodological approaches into an overall synthesis of the evidence. A systematic search of four electronic databases CINAHL, MEDLINE, EMBASE and PsycINFO was conducted between 2003 and 2024, with no geographical limits set due to the paucity of research published in this area.

FINDINGS

Eight studies met the inclusion criteria and were synthesised using thematic synthesis. Two main themes plus sub-themes were identified: (1) Knowledge and Skills (sub-themes: Communication; Clinical skills) and (2) Challenges (sub-themes: Attitudes; Resources).

CONCLUSIONS

Knowledge and skill deficits contribute to the difficulties healthcare professionals face when providing care to women with psychological birth trauma and birth related PTSD. A lack of referral pathways for women to receive the specialised support and treatment they require is also evidenced. This study is the first to our knowledge to examine healthcare professionals experiences of caring for women with psychological birth trauma and birth related post-traumatic stress disorder and make recommendations on how to prevent, identify and support affected women within the perinatal setting.

The conceptualisation and evolution of psychological birth trauma in the absence of identifiable risk factors: A scoping review

BACKGROUND

Psychological birth trauma is an emerging area of childbirth research lacking a universally accepted definition.This scoping review explores how psychological birth trauma has been conceptualised in the literature, focusing on perinatal women without identifiable risk factors (e.g., physical injury, maternal morbidity risk, or prior vulnerabilities).

OBJECTIVE

To understand the conceptualisation and evolution of psychological birth trauma according to the research literature, map the existing literature on psychological birth trauma, identify key elements and research gaps, and provide insights into the conceptual evolution of psychological birth trauma in the absence of identifiable risk factors.

METHODS

Seven databases (MEDLINE, CINAHL, PsycInfo, Scopus, Cochrane, Informit, Emcare) were searched for published, peer-reviewed studies on psychological birth trauma without identifiable risk factors.A scoping review following Arksey and O'Malley's framework synthesised findings from 231 articles.Data were charted to identify key elements and patterns.

RESULTS

Five key elements central to psychological birth trauma were identified: variables of psychological trauma, long-term psychological effects, relational and social dynamics, subjective appraisals, and cultural influences.Psychological birth trauma is distinct from broader terms like "birth trauma" or "traumatic childbirth," given its emphasis on emotional and psychological consequences.

CONCLUSION

Conceptual frameworks for psychological birth trauma and traumatic childbirth may guide future refinement and standardised terminology. Unique psychological dimensions are apparent in women who describe childbirth as traumatic despite lacking identifiable risk factors. This review underscores the need for multidisciplinary research to refine definitions and lays the groundwork for advancing conceptualisations and supporting women's wellbeing in childbirth.

Digital intervention for tokophobia: a randomized controlled trial of internet-based cognitive behavioral therapy on fear of childbirth and self-efficacy among Egyptian pregnant women

BACKGROUND

Tokophobia affects up to 14% of pregnant women globally and is linked to high cesarean rates, particularly in Egypt. This study evaluated the efficacy of a culturally adapted Internet-based Cognitive Behavioral Therapy program on fear of childbirth and maternal self-efficacy among Egyptian pregnant women.

METHODS

A randomized controlled trial was conducted in Damanhur City, Egypt, involving 96 pregnant women with moderate to severe tokophobia. Participants were randomly assigned to an intervention group (n = 48) receiving a six-week program via WhatsApp or a control group (n = 48) receiving routine antenatal care. The intervention included cognitive restructuring, exposure therapy, relaxation techniques, and psychoeducation grounded in Bandura's Self-Efficacy Theory. Outcomes were assessed using the Childbirth Attitude Questionnaire and Childbirth Self-Efficacy Inventory at baseline and post-intervention.

RESULTS

Post-intervention, the intervention group demonstrated a significant reduction in fear of childbirth scores (mean decrease: 14.32 ± 5.55; p < 0.001) and an increase in maternal self-efficacy (mean increase: 38.3 ± 35.7; p < 0.001). Large effect sizes were observed for both fear reduction (η²=0.876) and self-efficacy enhancement (η²=0.600). The control group showed no significant changes.

CONCLUSION

The culturally adapted Internet-based Cognitive Behavioral Therapy program significantly reduced tokophobia and enhanced maternal self-efficacy, supporting its integration into perinatal care. These findings align with Bandura's Self-Efficacy Theory and suggest the potential of digital interventions in improving psychological outcomes, especially in resource-limited settings.

IMPLICATIONS FOR PRACTICE

Integrating the program into routine antenatal care could provide accessible, cost-effective support for women experiencing tokophobia, potentially reducing unnecessary cesarean sections and informing health policy regarding the effectiveness of the ICBT program. Future research should assess long-term outcomes and generalizability in diverse populations.

TRIAL REGISTRATION

The study was registered on ClinicalTrials.gov under the identifier (NCT06640608) on October 15, 2024.

Practitioner perspectives on the use of selected fear of childbirth screening tools within a clinical context

Fear of childbirth (FOC), or tokophobia, can influence several medical and obstetric variables, and is a significant predictor of maternal and mental health outcomes and birth experiences. Current practice in the UK does not include initial screening for tokophobia, rather, assessment and support occur under extreme circumstances e.g. maternal requests for caesarean sections or pregnancy termination requests in order to avoid childbirth. Moreover, while there are several candidate outcome measures for FOC, none have been evaluated in terms of their perceived suitability by specialist practitioners within perinatal healthcare pathways. The present study explores the perceived barriers and facilitators reported by health professionals working within the maternity and mental health services for the use of FOC candidate outcome measures. Evaluated measures included the Fear of Birth Scale, the Oxford Worries about Labour Scale, The Wijma Delivery Expectancy Scale, the Slade-Pais Expectations of Childbirth Scale the Tokophobia Severity Scale. The Tokophobia Severity Scale, followed by the Slade-Pais Expectations of Childbirth Scales were the most favourable scales selected for use according to clinicians. The identification of preferred scales and how they can be used in the local maternity system is a step towards the application of these consistently in clinical practice, to aid in the identification and assessment of FOC. The use of the correct tool at each stage of contact with the local maternity system will improve clinician confidence in the identification of FOC and facilitate the efficient implementation of treatment and support through the development of pathways of care.

Effect of self-hypnosis on fear and pain of natural childbirth: a randomized controlled trial

OBJECTIVES

A clinical trial was conducted to address the trend of high cesarean section rates resulting from maternal fear of childbirth. This trial aimed to investigate the effectiveness of self-hypnosis in mitigating fear and pain during childbirth.

METHODS

This study was a parallel, not blinded, randomized controlled trial conducted in 2019 in Mashhad, Iran. Ninety-three nulliparous women were selected by convenience sampling and randomized by random allocation software (4 blocking groups) to either self-hypnosis or control groups. During the clinical trial, both groups received usual care for pregnancy and childbirth. However, the self-hypnosis group also participated in two hypnosis sessions and was given two audio files to practice self-hypnosis at home until delivery. The follow-up period ranged from the 37th week of pregnancy to the postpartum period. Fear of childbirth was assessed at 39 weeks and at cervical dilatation of 8-10 cm, while labor pain was measured at the same stage of labor as the primary outcomes between two groups. Data were analyzed using SPSS 16, applying the Independent sample t-test, Mann-Whitney U test, and Chi-square test. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Thirty women in the self-hypnosis group, aged 24.96±5.42, and 33 women in the control group, aged 23.63±4.68, completed the study. The average scores of fear of childbirth during pregnancy at 39 weeks (self-hypnosis: 46.46±14.53, control: 73.18±17.91), during the active phase of labor at cervical dilatation of 8-10 cm (self-hypnosis: 40.80±17.37, control: 75.12±19.40), and labor pain at cervical dilatation of 8-10 cm (self-hypnosis: 83.03±16.43, control: 95.36±10.36) were significantly lower in the self-hypnosis group compared to the control group (p<0.001 for all).

CONCLUSIONS

Our findings suggest that self-hypnosis could be a more effective intervention than usual care alone for reducing fear and pain during natural childbirth in nulliparous women.

Perinatal Depression, Labor Anxiety and Mental Well-Being of Polish Women During the Perinatal Period in a War and Economic Crisis

Objective: The armed conflict in Ukraine and its impact on Europe's economy have led to an war and economic crisis, potentially affecting the mental health of women during the perinatal period. This study aimed to assess the severity of depressive symptoms and labor anxiety among Polish women in perinatal period during this crisis.

Methods: From June 2, 2022, to April 11, 2023, 152 women completed three sets of online surveys-two during pregnancy (before 33 weeks and/or between 33 and 37 weeks) and one postpartum (4 weeks after childbirth). The questionnaires used to evaluate the anxiety and depressive symptoms included Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory (BDI-2), Labor Anxiety Questionnaire (LAQ), and team-developed questionnaires evaluating war-related anxiety (WAQ) and global situation anxiety (GSAQ) Statistical analyses included U-Mann Whitney, Kruskal-Wallis, Wilcoxon signed-rank, Friedman tests and Spearman's correlations, with a significance level set at p < .05.

Results: Among Polish pregnant women aged 23-43, 31.6% of participants experienced depressive symptoms, while 70.4% reported increased labor-related anxiety. Additionally, 24.3% experienced significant anxiety due to the war, and 25% suffered from severe anxiety related to the global situation. Positive correlations were noted between EPDS and GSAQ scores (R = 0.34, p < .001) and LAQ and WAQ scores (R = 0.21, p = .008).

Conclusions: The prevalence of perinatal depression is high during war and economic crisis, underscoring the urgent need to improve screening for perinatal depression in Poland. Further, the manuscript did not discuss symptom patterns across the three time points.

Factors influencing childbirth fear among Asian women: a scoping review

Fear of childbirth (FOC) or tokophobia adversely affects women during pregnancy, delivery, and postpartum. Childbirth fear may differ across regions and cultures. We aimed to identify factors influencing the fear of childbirth among the Asian population. A systematic literature search was performed using the PubMed, Scopus, and Web of Science databases in November 2023. Original articles in English with research conducted in Asian countries were included. The independent factors associated with childbirth fear, from the relevant studies were identified and discussed. Forty-six papers met the eligibility criteria but only 26 studies were discussed in this review. The significant factors were categorized into (1) demographics, (2) clinical, (3) healthcare service, (4) childbirth education & information, and (5) COVID-19 pandemic. The prevalence of childbirth fear among Asians ranged between 56.6 and 84.8%. Significant demographic factors included age, education, marital status, economic status, and area of residence. Greater levels of tokophobia were linked to nulliparity, unplanned pregnancy, infertility, miscarriage, and pregnancies at risk. Effective doctor-patient communication and more frequent antenatal visits were shown to alleviate maternal childbirth fear. There was consistent evidence of prenatal childbirth education's benefit in reducing FOC. The usage of smartphone apps and prolonged exposure to electronic devices were linked to a higher degree of tokophobia. Nulliparas who received too much pregnancy-related information also reported increased childbirth fear. There was a positive correlation between maternal fear of COVID-19 infection and FOC. Keeping updated with COVID-19 information increased the maternal childbirth fear by two-fold. In conclusion, a stable economy and relationship contribute to lesser childbirth fear among Asian women. Poor maternal health and pregnancy complications were positive predictors of FOC. Health practitioners may reduce maternal childbirth through women's education, clear communication as well as accurate information and guidance to expectant mothers. Further study is required into the content of childbirth fear among Asian women. These research findings hopefully will lead to the development of culturally adapted screening tools and interventions that reduce the burden of FOC among expectant mothers.

The relationship between traumatic childbirth perception, desire to avoid pregnancy, and sexual quality of life in women

OBJECTIVE

To identify factors influencing women's perceptions of traumatic childbirth (TCP) and to determine the relationship between TCP, desire to avoid pregnancy, and sexual quality of life.

METHODS

A descriptive and correlational research study was designed. Data were collected from 225 women aged between 18 and 45 years old. A Demographic Information Form, the Desire to Avoid Pregnancy Scale (DAP), the Sexual Quality of Life Questionnaire-Female (SQLQ-F), and the Perception of Traumatic Childbirth Scale (PTCS) were used for data collection.

RESULTS

Women who were not employed, had given birth previously, and did not plan their last pregnancy tended to have higher levels of TCP. Conversely, women who did not experience health problems in their last pregnancy and recalled their last childbirth as very comfortable and happy tended to have lower levels of TCP. A very weak, statistically significant, positive correlation was found between the mean DAP and PTCS scores (r = 0.168, P < 0.05). A very weak, statistically significant, negative correlation was found between the mean SQLQ-F and PTCS sores (r = -0.138, P < 0.05). A 1-unit increase in TCP was associated with a 0.005-unit increase in the desire to avoid pregnancy and a 0.094-unit decrease in sexual quality of life.

CONCLUSION

TCP in women is associated with an increase in the desire to avoid pregnancy and a decrease in sexual quality of life. It is recommended to identify women with high levels of TCP, determine factors contributing to this perception, and plan appropriate nursing interventions accordingly.

Trauma-informed support after a complicated childbirth - An early intervention to reduce symptoms of post-traumatic stress, fear of childbirth and mental illness

OBJECTIVE

Women who experience obstetric interventions and complications during childbirth have an increased risk of developing postnatal post-traumatic stress and mental illness. This study aimed to test the effect of a trauma-informed support programme based on psychological first aid (PFA) to reduce the mothers' symptoms of stress, fear of childbirth (FOC), anxiety and depression after a complicated childbirth.

METHODS

The study population consisted of women ≥ 18 years old who had undergone a complicated childbirth (i.e. acute or emergency caesarean section, vacuum extraction, child in need of neonatal care, manual placenta removal, obstetric anal sphincter injury, shoulder dystocia or major haemorrhage (>1000 ml)). A total of 101 women participated in the study, of whom 43 received the intervention. Demographic questions and three self-assessment instruments measuring stress symptoms, FOC, anxiety and depression were answered one to three months after birth.

RESULTS

The women in the intervention group scored significantly lower on the stress symptom scale, with a halved median score compared to the control group. There was no significant difference between the groups regarding FOC, depression and anxiety.

CONCLUSION

Our results indicate that this PFA-based support programme might reduce post-traumatic stress symptoms in women who have gone through a complicated childbirth. With further studies in a larger population, this support programme has the potential to contribute to improved maternal care optimizing postnatal mental health.

Fear of childbirth and its associated factors among pregnant women in Dejen Woreda, East Gojjam Zone, Northwest Ethiopia: a community-based cross-sectional study

Fears of delivery are the uncertainty and worry experienced before, during, and following labor. It hurts women's health and affects 5-40% of all moms globally. If not recognized, it could cause expectant mothers to feel alone and unsupported. Studies on this subject, however, are scarce at the woreda level. Therefore, this study amis to assess the prevalence and associated factors of fear of childbirth among pregnant women in Dejen Woreda, East Gojjam Zone, Northwest Ethiopia. A community-based cross-sectional study was conducted among 575 pregnant women selected by Cluster Sapling from December 15 to December 25, 2022. Data were gathered using a structured questionnaire that was presented by an interviewer. Data were entered using Epi-data version 3.1 and analyzed using SPSS Version 23 statistical software. Descriptive statistics and inferential statistics were done, and ordinary logistic regression was used to examine the associated factor for fear of childbirth. Finally, a P-value < 0.05 was used to determine statistical significance. Among the 575 pregnant women supposed to have participated, 560 agreed and participated in the survey, with a response rate of 97.4%. This study showed that 133(23.8%; CI 20.4-26.8) of the study participants had low fear of childbirth, 67(12%; CI (9.3-14.8 moderate, 217 (38.8%; CI 34.6-42.7) high, 143 (25.5%; CI 21.8-29.1) severe fear of childbirth. Having maternal age 18-24 (adjusted odds ratio/AOR = 1.6; 95% CI (1.1-2.3), p-value = -0.08), occupation daily laborer and other (AOR = 0.3,95%; CI 0.3, 0-74; p-value = 0.004),gestational age in third trimester (AOR = 1.9,95%; CI 1.1-3.4), p-value = 0.022) showed significant factor for a fear of childbirth. Maternal age, occupation, and third-trimester pregnancy were found to be significantly associated with fear of childbirth. Women should engage in special attention to keep them healthy by consistent monitoring during pregnancy. Healthcare providers should identify pregnant women with high fear of childbirth early, offer cognitive behavioral therapy, support psychological and physical well-being, provide early age and preventive measures, and use uniform instruments for assessing women's anxiety, promoting systematic reviews and longitudinal studies.

Validity and reliability of the Greek version of Wijma delivery expectancy/experience questionnaire (Version A) among low-risk pregnant women

BACKGROUND

Fear of childbirth is a frequent health issue for pregnant women. The Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) is a widely used instrument to measure the fear of childbirth during the antenatal period. The aim of the study was to assess the psychometric properties of the W-DEQ (version A) in a sample of Greek pregnant women.

METHODS

Low-risk pregnant women in the second or third trimester of pregnancy (N = 201) were invited to participate in the study and to complete a booklet of questionnaires including the Greek versions of W-DEQ-A, State-Trait Anxiety Inventory (STAI), Coping Orientations to Problems Experienced (Brief COPE), Perceived Stress Scale (PSS-10) and Edinburgh Postnatal Depression Scale (EPDS). Exploratory (EFA) and confirmatory factor analysis (CFA) was performed.

RESULTS

The mean age of participants was 34.2 years (SD = 4.3 years). EFA yielded six factors ("Lack of self-efficacy", "Lack of positive anticipation", "Lack of feeling lonely", "Concerns about delivery and losing control", "Calmness", and "Concern for the child") of 33 items of W-DEQ-A. CFA confirmed the multidimensionality of the instrument. All Cronbach's alpha were over 0.7, indicating acceptable reliability of the factors. All factors were significantly correlated with each other, and convergent validity was demonstrated by a significant association with stress, anxiety, and depression among low-risk pregnant women.

CONCLUSION

The Greek version of W-DEQ-A proved to be a valid and reliable instrument of fear of childbirth among Greek low-risk pregnant women.

The effect of continuous intrapartum supportive care on maternal mental health: a randomized controlled trial

Supportive care during labor is the primary role of intrapartum nurses and midwives and provides comfort for women allowing them to have a positive experience. It is argued that supportive care during labor reduces fear and resultant side effects. However, evidence for different parameters of mental health is insufficient. The aim of this study was to evaluate the effect of continuous intrapartum supportive care on the fear of childbirth, perceived control and support at birth, birth trauma and maternal attachment. This is a randomized controlled study with an intervention group and a control group. The intervention group included 40 women receiving continuous intrapartum supportive care and the control group included 40 women receiving routine care. Thirty women in the intervention group and 29 women in the control group completed the study. No significant differences were detected between the two groups at baseline (p > .05). Continuous intrapartum supportive care significantly decreased fear of birth and birth trauma, and significantly increased perceived intrapartum control and support and postpartum maternal attachment (p < .01). Results from this evidence-based study suggest that continuous intrapartum supportive care could protect and maintain perinatal mental health.

Investigating Factors Influencing Prenatal Stress, Anxiety, and Fear of Childbirth During the COVID-19 Pandemic in Germany and Switzerland: An Online Survey

OBJECTIVES

Pregnant women are likely to experience high levels of stress during the COVID-19 pandemic. However, the factors that might influence the extent of experienced emotional distress are poorly understood. Therefore, we aimed to investigate potential correlates of prenatal emotional distress during the COVID-19 pandemic.

METHODS

In total, N = 1437 pregnant women from Germany and Switzerland participated in an online study during the first wave of the COVID-19 pandemic (May-August 2020). The survey assessed prenatal distress, pandemic-related pregnancy stress, general anxiety, fear of childbirth, and several socio-demographic, pregnancy- and COVID-19-related factors. Linear multivariate regression models were the main analytical strategy.

RESULTS

The results highlight that several factors such as full-time employment, nulliparity, high-risk pregnancy, emotional problems, cancelled prenatal appointments, and stating that COVID-19 affected the choice of birth mode were significantly associated with elevated prenatal distress, anxiety, pandemic-related pregnancy stress, and fear of childbirth. Conversely, access to an outdoor space was a protective factor for pandemic-related pregnancy stress and prenatal distress.

CONCLUSIONS FOR PRACTICE

Overall, the study highlights significant correlates influencing the levels of emotional distress pregnant women experienced during the COVID-19 pandemic. These findings may contribute to the improvement of maternal prenatal medical and psychological care during a public health crisis of international concern, such as the COVID-19 pandemic.

Traumatic childbirth experiences, effects and coping: A qualitative study

OBJECTIVE

Childbirth experience and perception of birth are personal. It is important to understand how the traumatic childbirth experiences affected women and for the nursing care that would be given to them. The aim of the research was to determine the childbirth experiences perceived by women as traumatic, how they were affected by these experiences, and how they coped.

METHODS

The study was a descriptive phenomenological approach study. The data were obtained through semi-structured, in-depth individual interviews. Content analysis was used in the analysis of the data. The mothers were contacted by using the social media platforms. Sixteen women were included in the research who expressed that they had traumatic childbirth experiences.

RESULTS

It was determined that women experienced severe fear and pain during childbirth, that they were in unsuitable maternity hospital environments, and that care was not taken for their privacy. At the same time, it was determined that they experienced disorders in the postpartum period connected to their traumatic birth experiences, that they postponed their pregnancy plans due to their fear of childbirth that developed connected to traumatic childbirth or that they did not want to become pregnant, and that they did not receive sufficient support from health personnel.

CONCLUSION

It is necessary to provide privacy during childbirth, to take into consideration the decisions of women, and to provide for their continuous support by midwives.

NICU parents' mental health: A comparative study with parents of term and healthy infants

AIM

To compare mental health in parents of preterm/ill infants and parents of term and healthy infants before birth and 1 month after hospital discharge.

METHODS

A comparative cohort design was used. In total 439 parents from six neonatal intensive care units (NICUs) and 484 parents from four maternity units (MUs) in Sweden answered a survey 1 month after discharge.

RESULTS

Parents in neonatal units experienced significantly more psychologically traumatic births and rated their health and the health of their infants less favourably the first week after delivery than parents in MUs. In the neonatal units, both parents had better possibilities to stay together with the infant during hospital stay. There was no difference between the NICU and MU groups in postpartum depressive symptoms 1 month after discharge. Experiencing a traumatic birth was not related to an increased risk of perinatal depressive symptoms (Edinburgh Postnatal Depression Scale ≥13) for mothers in NICUs. In contrast, the risk of depression increased for mothers in MUs.

CONCLUSION

Family togetherness, parent-infant closeness and emotional support at NICUs may contribute to the positive outcome. Further studies are needed to assess the long-term effects of how family togetherness and closeness influence families long term.

Transition to Motherhood: A Study on the Association between Somatic Symptoms during Pregnancy and Post-Partum Anxiety and Depression Symptoms

Several authors found that somatic symptoms during pregnancy such as nausea, vomiting, and levels of sleep, and fear of childbirth were associated with women's post-partum psychopathological difficulties. The present study aimed to verify whether fear of childbirth can mediate the relationship between some somatic symptoms experienced during pregnancy (i.e., nausea, vomiting, and daily sleep duration) and the post-partum depressive and anxious symptoms. N = 258 mothers of children between 3 and 6 months of age filled out self-report questionnaires assessing somatic symptoms during pregnancy, fear of childbirth, and anxious and depressive symptoms during post-partum. Results showed that levels of vomiting during pregnancy (but not nausea and daily sleep duration) was associated with post-partum depression and anxiety. Furthermore, findings showed that fear of childbirth partially mediated the relationships between the levels of vomiting during pregnancy and post-partum state anxiety and depression. These results can have several clinical implications, allowing to implement preventive programs for post-partum depression, considering vomiting and fear of childbirth as important risk factors.

Longitudinal path analysis for the directional association of depression, anxiety and posttraumatic stress disorder with their comorbidities and associated factors among postpartum women in Northwest Ethiopia: A cross-lagged autoregressive modelling study

INTRODUCTION

Vulnerability for depression, anxiety and posttraumatic stress disorder symptoms due to perceived traumatic birth increase during the postpartum period. Traumatic birth has been defined as an event occurring during labour and birth that may be a serious threat to the life and safety of the mother and/or child. However, the comorbidity and multimorbidity of depression, anxiety and PTSD with their direct and indirect predictors is not well investigated in the postpartum period. In addition, the longitudinal directional association of depression, anxiety and PTSD with their comorbidities is not studied in Ethiopia.

OBJECTIVE

The aim of this study was to assess prevalence of postnatal comorbid and multimorbid anxiety, depression and PTSD. It also aimed to determine the directional association of postnatal anxiety, depression and PTSD with the comorbidity and multimorbidity of these mental health problems over time and to explore the factors that are directly or indirectly associated with comorbidity and multimorbidity of anxiety, depression and PTSD.

METHODS

A total of 775 women were included at the first, second and third follow-up of the study (6th, 12th and 18th week of postpartum period) during October, 2020 -March, 2021. A cross-lagged autoregressive path analysis was carried out using Stata 16.0 software in order to determine the autoregressive and cross-lagged effects of depression, anxiety and PTSD with their comorbidities. In addition, a linear structural equation modelling was also carried out to determine the direct and indirect effects of independent variables on the comorbidities of depression, anxiety and PTSD.

RESULTS

Comorbidity of anxiety with depression was the most common (14.5%, 12.1% and 8.1%) at the 6th, 12th and 18th week of postnatal period respectively. With regard to the direction of association, comorbidity of PTSD (due to perceived traumatic birth) with depression, PTSD with anxiety, depression with anxiety and triple comorbidity predicted depression and anxiety in subsequent waves of measurement. Direct and indirect maternal morbidity, fear of childbirth and perceived traumatic childbirth were found to have a direct and indirect positive association with comorbidities of depression, anxiety and PTSD. In contrast, higher parity, higher family size and higher social support had a direct and indirect negative association with these mental health disorders.

CONCLUSION

Postnatal mental health screening, early diagnosis and treatment of maternal morbidities, developing encouraging strategies for social support and providing adequate information about birth procedures and response to mothers' needs during childbirth are essential to avert comorbidity of anxiety, depression and PTSD in the postpartum period.

'After last time, would you trust them?' - Rebuilding trust in midwives after a traumatic birth

AIM

To explore the processes pregnant women used to rebuild their trust in midwives and obstetricians, after a previous traumatic birth.

DESIGN

A longitudinal feminist constructivist Grounded Theory methods study, using semi-structured interviews to investigate how women made sense of their journeys through pregnancy and maternity care, when they had previously experienced a traumatic birth.

SETTING

Nine UK women were recruited in early pregnancy via the internet and social media, and were interviewed three times during the perinatal period.

FINDINGS

During pregnancy, participants re-analysed their previous birth experience(s) in order to plan for this pregnancy and birth. Once they had conceptualised their plans, they sought out healthcare professionals who could offer support, and used naturally occurring or engineered trust diagnostic situations to establish whether trust could be rebuilt.

CONCLUSION

Without a trusting relationship, midwives and obstetricians cannot deliver appropriate and efficient healthcare to pregnant people. Understanding the processes that pregnant women utilise to rebuild trust may help healthcare professionals to better understand their role in re-establishing these relationships.

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.

Longitudinal mediation analysis of the factors associated with trajectories of posttraumatic stress disorder symptoms among postpartum women in Northwest Ethiopia: Application of the Karlson-Holm-Breen (KHB) method

INTRODUCTION

In recent years, literatures identified childbirth as a potentially traumatic experience resulting in posttraumatic stress disorder (PTSD), with 19.7 to 45.5% of women perceiving their childbirth as traumatic. A substantial variation in PTSD symptoms has been also indicated among women who experience a traumatic childbirth. However, there has been no research that has systematically investigated these patterns and their underlying determinants in postpartum women in Ethiopia.

OBJECTIVE

The aim of this study was to investigate the trajectories of PTSD symptoms and mediating relationships of variables associated with it among postpartum women in Northwest Ethiopia.

METHODS

A total of 775 women were recruited after childbirth and were followed at the 6th, 12th and 18th week of postpartum period during October, 2020 -March, 2021. A group-based trajectory modeling and mediation analysis using KHB method were carried out using Stata version 16 software in order to determine the trajectories of PTSD symptoms and mediation percentage of each mediator on the trajectories of PTSD symptoms.

RESULTS

Four distinct trajectories of postpartum posttraumatic stress disorder symptoms were identified. Perceived traumatic childbirth, fear of childbirth, depression, anxiety, psychological violence, higher WHODAS 2.0 total score, multigravidity, stressful life events of health risk, relational problems and income instability were found to be predictors of PTSD with recovery and chronic PTSD trajectory group membership. Depression and anxiety not only were strongly related to trajectories of PTSD symptoms directly but also mediated much of the effect of the other factors on trajectories of PTSD symptoms. In contrast, multiparity and higher mental quality of life scores were protective of belonging to the PTSD with recovery and chronic PTSD trajectory group membership.

CONCLUSION

Women with symptoms of depression, anxiety, fear of childbirth and perceived traumatic childbirth were at increased risk of belonging to recovered and chronic PTSD trajectories. Postnatal screening and treatment of depression and anxiety may contribute to decrease PTSD symptoms of women in the postpartum period. Providing adequate information about birth procedures and response to mothers' needs during childbirth and training of health care providers to be mindful of factors that contribute to negative appraisals of childbirth are essential to reduce fear of childbirth and traumatic childbirth so as to prevent PTSD symptoms in the postpartum period.

Validation and Psychometric Properties of the Spanish Version of the Fear of Childbirth Questionnaire (CFQ-e)

The fear of childbirth is a topical concern, yet the issue has barely been studied in Spain, and only one fear of childbirth measurement instrument has been validated in the country. The aim of this study was to translate, adapt and validate the Fear of Childbirth Questionnaire (CFQ) for use in Spain, as well as to describe and evaluate the psychometric properties of the Spanish version of this instrument. In a first phase, a methodological study was carried out (translation–backtranslation and cross-cultural adaptation), and pilot study was carried out in the target population. In addition, content validation of the instrument was obtained (CFQ-e) from 10 experts. In the second phase, a cross-sectional study was carried out at several centres in Gran Canaria Island to obtain a validation sample. The evaluation of the psychometric properties of the CFQ-e, including construct validity through exploratory factor analysis and confirmatory factor analysis, the calculation of reliability via factor consistency using the ORION coefficients as well as alpha and omega coefficients were carried out. The CFQ-e showed evidence of content validity, adequate construct validity and reliability. The CFQ-e is composed of 37 items distributed in four subscales or dimensions: “fear of medical interventions”; “fear of harm and dying”; “fear of pain” and “fears relating to sexual aspects and embarrassment”. The CFQ-e constitutes a valid and reliable tool to measure the fear of childbirth in the Spanish pregnant population.

Fear of childbirth postpartum and its correlation with post-traumatic stress symptoms and quality of life among women with birth complications - a cross-sectional study

The primary aim of the study was to analyze differences in post-traumatic stress symptoms (PTSS) and quality of life (QoL) between women with and without severe fear of childbirth postpartum (PP FOC). The secondary aims were to analyze the correlation between PP FOC and PTSS, and PP FOC and QoL, in women undergoing complicated childbirth. This cross-sectional study was conducted in South-East Sweden. Women aged ≥ 18 years who had undergone complicated childbirth (i.e., acute or emergency cesarean section, vacuum extraction, child in need of neonatal care, manual placenta removal, sphincter rupture, shoulder dystocia, or hemorrhage ≥ 1000 ml) were invited. Seventy-six women answered demographic questions and three validated instruments measuring PP FOC, PTSS, and QoL. The study population was divided into two sub groups: severe PP FOC or no severe PP FOC. Statistical analyses were conducted using Mann-Whitney U-test, chi-square test or Fisher's exact test, and Spearman's rank-order correlation. Severe PP FOC was reported by 29% of the women, and 18% reported PTSS indicating post-traumatic stress disorder. Women with severe PP FOC reported significantly higher levels of PTSS, and significantly lower QoL in five dimensions: physical role functioning, emotional role functioning, energy/fatigue, emotional well-being, and social functioning. There was a positive significant correlation between level of PP FOC and PTSS. There were also significant negative correlations between level of PP FOC and most of the QoL dimensions. In conclusion, almost one-third of the women with complicated childbirth reported severe PP FOC, and almost one-fifth reported PTSS indicating post-traumatic stress disorder. PP FOC correlated with PTSS and deteriorated QoL.

A scoping review of maternity care providers experience of primary trauma within their childbirthing journey

OBJECTIVE

To examine and summarise available literature on maternity care practitioners having experienced primary trauma during their childbirthing journey and whether this impacts their mental well-being and/or care provision when subsequently caring for childbearing women.

BACKGROUND

Birth trauma affects 1 in 3 women; 1 in 20 women show post-traumatic stress disorder symptoms by 12 weeks after birth. However, what is not known is what percentage of these women are maternity care providers experiencing or having experienced personal trauma during their child birthing journey. This scoping review aims to examine and summarise available literature on maternity care practitioners having experienced primary trauma during their childbirthing journey and whether this impacts their mental well-being and/or care provision when subsequently caring for childbearing women.

METHODS

Arksey and O'Malley (2005) six-stage scoping review framework was revised and utilised. A search of the relevant databases (MEDLINE Embase, CINAHL, APA PsycInfo, Scopus) was undertaken with several keywords related to trauma and personal experience. Reference lists were also searched of studies identified for reading the full text.

FINDINGS

The search strategy identified 2983 articles. The studies excluded were considered to be unrelated to the topic directly. A total of 352 articles were reviewed by abstract, and 29 additional studies were identified from reference lists; 32 were reviewed by full text. A total of 0 studies met the inclusion criteria for the scoping review.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The scoping review identified a gap in the literature as maternity care practitioners personal experience of trauma during the child birthing journey has not been researched. Research is needed to explore and conceptualise the experiences of maternity care practitioners having experienced trauma and the ongoing implications this may have on their personal and professional lives.

Prospective risk from prenatal anxiety to post traumatic stress following childbirth: The mediating effects of acute stress assessed during the postnatal hospital stay and preliminary evidence for moderating effects of doula care

OBJECTIVE

Growing literature has identified childbirth as a potentially traumatic event, following which mothers may develop symptoms of Post-Traumatic-Stress-Following-Childbirth. The current study is the first to prospectively examine a pathway of risk from mothers' prenatal trait-anxiety, to Acute-Stress-Immediately-Following-Childbirth, and later symptoms of Post-Traumatic-Stress-Following-Childbirth, in a low-risk community sample. Auxiliary analyses explored whether doula care during childbirth moderated risk.

METHOD

149 pregnant women were randomly selected. Prenatal trait-anxiety was assessed toward the end of pregnancy, Acute-Stress-Immediately-Following-Childbirth at two-days post-partum, and symptoms of Post-Traumatic-Stress-Following-Childbirth at one-month post-partum.

RESULTS

Results indicated a significant indirect pathway from prenatal trait-anxiety to Post-Traumatic-Stress-Following-Childbirth, through Acute-Stress-Immediately-Following-Childbirth. Two groups were generated ad hoc for auxiliary analyses: participants who opted to receive doula care during childbirth (n=21; 14%) versus participants who received care as usual (n=128; 86%). Analyses provided preliminary support for doula care as a potential moderator of risk.

CONCLUSIONS

Results point toward prenatal trait-anxiety and Acute-Stress-Immediately-Following-Childbirth as significant risk factors for Post-Traumatic-Stress-Following-Childbirth. Findings inform preventive screening implicating the prenatal period as well as the postnatal hospital stay as important time windows for preventive screening. Finally, preliminary support for moderating effects of doula care suggest that preventive interventions administered during the perinatal period may effectively reduce anxiety-related risk for Post-Traumatic-Stress-Following-Childbirth.

Reconsidering fear of birth: Language matters

Interest in fear of childbirth has grown exponentially since the 1980s, but the landscape of birth has shifted considerably since then, with evolving feminism; moving from a patriarchal environment in a biomedical model of care to a holistic model which recognizes the birth and sexuality rights of women and birthing people. Distinguishing the spectrum of fear from low to high and severe is important rather than aggregating all individuals with fear of childbirth. However, the terms 'fear of childbirth' and 'tocophobia' have been used interchangeably. In this paper we urge clinicians to use the term 'tocophobia' with caution since it may be construed negatively and there is a limited understanding of the underpinning aetiology of tocophobia. Furthermore, using the label may be disempowering for women and birthing people making decisions about their birth. Further research is warranted to better understand the experience, refine and define the issue and meet the individual needs of people with fear of childbirth and tocophobia.

Mental health problems and fear of childbirth: A cohort study of women in an inner-city maternity service

OBJECTIVES

To estimate the population prevalence of severe fear of childbirth (FOC) during pregnancy and investigate its association with: (a) antenatal common mental disorders (depression and anxiety disorder) and (b) elective cesarean birth.

METHODS

545 participants from an inner-city London maternity population were interviewed soon after their first antenatal appointment (mean gestation: 14 weeks). Current mental disorders were assessed using the Structured Clinical Interview DSM-IV. FOC was measured using the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ-A) at approximately 28 weeks gestation (n = 377), with severe FOC defined using a cutoff of WDEQ-A ≥ 85. Birth mode information was collected at 3 months post-delivery using an adapted Adult Service Use Schedule. Linear regressions were used to model associations, adjusting for the effects of covariates (age, parity, relationship status, education, and planned pregnancy). Sampling weights were used to adjust for bias introduced by the stratified sampling. We also accounted for missing data within the analysis.

RESULTS

The estimated population prevalence of severe FOC was 3% (95% CI: 2%-6%) (n = 377). Depression and anxiety were significantly associated with severe FOC after adjustment for covariates (45% vs 11%; coefficient: 15.75, 95% CI: 8.08-23.42, P < .001). There was a weak association between severe FOC and elective cesarean birth.

CONCLUSIONS

Severe FOC occurs in around 3% of the population. Depression and anxiety are associated with FOC. Pregnant people with depression and anxiety may be at increased risk of experiencing severe FOC. Attitudes toward childbirth should be assessed as part of routine clinical assessment of pregnant people in contact with mental health services.

Fear of Childbirth and Associated Factors Among Pregnant Mothers Who Attend Antenatal Care Service at Jinka Public Health Facilities, Jinka Town, Southern Ethiopia

BACKGROUND

Women face many challenges from conception to postpartum, and fear of childbirth is one of the challenges the women encounter during pregnancy. This could have resulted from different perspectives and it could in turn lead to various pregnancy and childbirth problems. Thus, understanding childbirth fear and factors associated with this is of paramount importance and this study was aimed at addressing this issue.

METHODOLOGY

A facility-based cross-sectional study was done on 423 pregnant mothers who came for antenatal care services at Jinka hospital and Jinka health center. The study was conducted from June 1to 30, 2018. The sample size was calculated using the single population proportion formula and samples were taken after proportional allocation was done for the hospital and health center using the proportion allocation formula. Individual participants were selected with a systematic sampling technique using k-value of 2 for both the hospital and health center and the first participant was selected by the lottery method from the first two samples. Data were entered into epi-data version 3.1.1. and exported into statistical packages for social sciences version 21.0 for cleaning and further analysis. The level of significance was declared at a p value of less than 0.05 in multivariable logistic regression model. Narratives, figures, and tables were used to put the result.

RESULT

From 423 samples, two of the questionnaires were incomplete and thus 421 were used for analysis giving a response rate of 99.5%. Around a quarter of 102 (24.2%) mothers had fear of childbirth and the remaining 319 (75.8%) had no fear of childbirth. From the factors under consideration, history of previous pregnancy complications, previous history of labor and delivery complications, educational status, and depression status were significantly associated with a mother's fear of childbirth.

CONCLUSION

Even though it is physiological to have some fear of childbirth, the figure obtained is relatively higher. Factors found to have a significant effect on childbirth fear are those which could be tackled through improved health literacy and integrated maternal health services.

The use of personal protective equipment as an independent factor for developing depressive and post-traumatic stress symptoms in the postpartum period

Background

New recommendations regarding the use of personal protective equipment (PPE) during delivery have changed the maternal birth experience. In this study, we investigated the mental perceived impact of PPE use during delivery on the development of maternal postpartum depression (PPD) and post-traumatic stress symptoms (PTSS).

Methods

This was a multicenter, retrospective cohort study concerning women who delivered during the COVID-19 pandemic first lockdown period in Israel. Postpartum women were approached and asked to complete a comprehensive online questionnaire. Impact of PPE was graded on a scale of 1–5, and Impact of PPE ≥4 was considered high. PPD and PTSS were assessed using the EPDS and City BiTS questionnaires.

Results

Of 421 parturients, 36 (9%) reported high Impact of PPE. Parturients with high Impact of PPE had significantly higher PPD and PTSS scores)EPDS 8.4 ± 5.8 vs. 5.7 ± 5.3; City BiTS 9.2 ± 10.3 vs. 5.8 ± 7.8, p < 0.05 for both). Following adjustment for socio-demographic and delivery confounders and fear of COVID-19 (using Fear of COVID19 scale), Impact of PPE remained positively correlated with PPD symptoms (ß = 0.103, 95% confidence intervals [CI] 0.029–1.006, p = 0.038).

Conclusion

When examining the risk factors for developing postpartum PTSS—experiences during labor and PPE were found to be significant variables. As the use of PPE is crucial in this era of COVID-19 pandemic in order to protect both parturients and caregivers, creative measures should be taken in order to overcome the communication gap it poses.

Psychometric properties of the Persian version of delivery fear scale (DFS) in Iran

BACKGROUND

The aim of the present study was to evaluate the psychometric properties of the Persian version of delivery fear scale (DFS) among Iranian women population.

METHODS

This is a methodological study that was conducted to evaluate the psychometric properties of DFS. Convenience sampling was used to select 200 pregnant women from the maternity ward of Razi Hospital in Ahvaz, Iran. In the first step, the scale was translated into Persian using backward-forward translation method. Afterwards, the following types of validity were examined: face validity based on impact score, construct validity based on confirmatory factor analysis (CFA), and concurrent validity. The Pearson correlation test was used to determine the correlation of DFS with pregnancy-related anxiety questionnaire (PRAQ), Childbirth Attitude Questionnaire (CAQ), Spielberger's state-trait anxiety inventory (STAI), and the short form of Lowe's childbirth self-efficacy inventory. Reliability of DFS was assessed by determining internal consistency (Cronbach's alpha) and split-half method.

RESULTS

CFA had satisfactory validity considering x²⁄df < 5 and the RMSEA < 0.08. /the obtained Cronbach's alpha coefficient was 0.77. The split-half coefficient of the questionnaire was 0.83, indicating an acceptable reliability for the questionnaire. The results showed that DFS had a direct significant correlation with the CAQ (r = 0.72), PRAQ (r = 0.74), STAI-Y1 (r = 0.71) and STAI-Y1 (r = 0.63) and a reverse significant correlation with subscales of the short form of Lowe's childbirth self-efficacy inventory including outcome expectancy (r= -0.75) and self-efficacy expectancy (r= -0.76).

CONCLUSIONS

The findings of the present study confirm the validity and reliability of the Persian version of DFS as an instrument for measuring fear of childbirth (FOC) in Iranian women population.

A qualitative study exploring the experience of psychotherapists working with birth trauma

As many as 45% of women experience birth trauma. Psychotherapists' knowledgeable insights are largely absent in literature, and therefore the objective of this research is to gain a comprehensive understanding of how psychotherapists in the UK experience the therapeutic process when working with women who have experienced a traumatic birth. Interpretive Phenomenological Analysis (IPA) was employed to examine the data coming from psychotherapists working with birth trauma. Three ostensible areas of focus were revealed: i) Hearing the story: discovering the altered-self, ii) Working with the story: enabling redemption of the altered-self, and iii) Professional challenges and the wider story: advocating for the altered-self. Birth trauma commonly leads to an altered sense of self, intertwined with a perception of loss regarding the birth experience and autonomy. Working with the client's birth story, to enable redemption and restore reasoning, is integral to the therapeutic process. Stabilisation and consideration of the presence of the baby are also significant. Integrating approaches produces positive outcomes. There is a purported gap in NHS services, professionals either lacking knowledge and misdiagnosing, or being limited by the emphasis placed on Cognitive Behavioural Therapy. For the therapeutic process consider: the sense of loss associated with the birth; working with the client's birth story to enable redemption and restore reasoning; the impact of the presence of the baby and the need for stabilisation; birth trauma as unique. For frontline health professionals: implementing existing screening protocols and undergoing training to recognise birth trauma may reduce misdiagnosis.

[Validation of the questionnaire for assessing the childbirth experience (QACE) in a French population]

BACKGROUND

A woman's negative perception of her subjective childbirth experience can have consequences on the mother's psychological state and on early mother-baby relationships. To date, there is no validated tool in France allowing to evaluate childbirth experience in a multidimensional way. The aim of this study is to validate the Questionnaire Assessing the Childbirth Experience (QEVA) in a French sample of mothers. This tool was developed in a previous study where the authors combined 25 items into 6 dimensions: representations and expectations, sensory perceptions, feeling of control, perceived social support (medical staff and partner), emotions (positive and negative) and first moments with the baby.

METHODS

The sample included 256 women recruited in a maternity ward. Sociodemographic and obstetric characteristics of our sample were compared to those of the French national perinatal survey. The structure of the QEVA with 17 items was explored by an exploratory structural equation modeling (ESEM). An analysis of the internal consistency was conducted on the sub-scores of the identified factors, and the concurrent validity was assessed with the Peri-traumatic Distress Inventory (PDI) through a correlation and its associated t-test.

RESULTS

The characteristics of our sample and those of the national perinatal survey do not differ on age, marital status, parity, cannabis use, infertility treatment, epidural and baby weight, in favour of the good representativeness of our sample. The study of the QEVA structure revealed a 4-dimensional structure. Analysis of the psychometric qualities showed a good internal consistency, with an observed alpha value ranging from 0.69 to 0.86. The QEVA also shows a good concurrent validity with the peri-traumatic distress scores (r=0.51).

CONCLUSION

To date, the QEVA is the first standardized tool allowing a multidimensional evaluation of the subjective experience of childbirth. It has been validated on a French population using an exploratory structural equation modeling. This tool, which is simple to use and well accepted by mothers, enables health professionals not only to screen mothers experiencing difficult childbirth and in need of support, but also to adapt health care according to the dimensions of the birth experience and its associated difficulties (emotions during the birth, interactions with health professionals, first moments with the baby, or post-partum emotions).

Identifying fear of childbirth in a UK population: qualitative examination of the clarity and acceptability of existing measurement tools in a small UK sample

Background

Fear of childbirth is related to but not synonymous with general anxiety, and represents a superior predictor for maternal and infant outcomes. There is a need to improve the identification and provision of support for women experiencing high fear of childbirth. However it is uncertain as to whether existing measurement tools have appropriate content validity (i.e. cover the relevant domains within the construct), practical utility, and whether they are acceptable for use with a UK population. This study aimed to (1) identify the utility and acceptability of existing measures of fear of childbirth (FOC) with a small UK sample and (2) map the content of existing measures to the key concepts of fear of childbirth established by previous research.

Methods

Ten pregnant women; five with high and five with low fear of childbirth participated in a cognitive interview covering four most commonly used measures of fear of childbirth: 1. The Wijma Delivery Expectancy Questionnaire (WDEQ A), 2. The Oxford Worries about Labour Scale (OWLS), 3. The Slade-Pais Expectations of Childbirth Scale – fear subscale (SPECS) and 4. The Fear of Birth scale (FOBS). Each measure was also reviewed by participants for ease and clarity of understanding and acceptability. The measures were then reviewed against the key domains identified in the fear of childbirth literature to ascertain the adequacy of content validity of each measure. Interviews were analysed using thematic analysis for each scale item.

Results

All measures except the FOBS, included items that either women did not understand or, if where there was understanding the meanings were inconsistent across women. All measures demonstrated limited acceptability and content validity for the specific construct of FOC. Therefore, none of the measurement tools currently used within the UK met criteria for understanding, acceptability and content validity for measurement of FOC.

Conclusions

Findings emphasise a need to develop a specific fear of childbirth tool with good clarity which demonstrates appropriate content validity, and that is acceptable in presentation and length for pregnant women in a UK population.

Incidence and Determinants of Caesarean Section in Shiraz, Iran

The rate of Caesarean section (CS) without medical indication has increased markedly worldwide in the past decades. This study reports the incidence of CS and identifies the determinants of elective and emergency CS as separate pregnancy outcomes in a cohort of Iranian women. Mothers (n = 700) of healthy, full-term infants were recruited from five maternity hospitals in Shiraz. The association between maternal socio-demographic and biomedical factors with mode of delivery was explored using multivariable, multinomial logistic regression. Most mothers underwent either an elective (35.4%) or emergency (34.7%) CS. After adjustment, women were more likely to deliver by elective CS than vaginally if they were older (≥30 year) compared to younger mothers (<25 year) (Relative Risk Ratio (RRR) 2.22; 95% Confidence Interval (CI) 1.28, 3.84), and had given birth at a private hospital (RRR 3.64; 95% CI 1.79, 7.38). Compared to those educated to primary or lower secondary level, university educated women were more likely to have undergone an elective (RRR 2.65; 95% CI 1.54, 4.58) or an emergency CS (RRR 3.92; 95% CI 2.27, 6.78) than a vaginal delivery. Similarly, overweight or obese women were more likely than healthy weight women to have undergone an elective (RRR 1.91; 95% CI 1.27, 2.87) or an emergency CS (RRR 2.02; 95% CI 1.35, 3.02) than a vaginal delivery. Specialist education of obstetricians and midwives along with financial incentives paid to private hospitals to encourage natural delivery may help in the reduction of unnecessary CS in Iran. In addition, to increase their childbirth knowledge and self-efficacy, pregnant women need to have the opportunity to attend purposefully designed antenatal childbirth preparation classes where they receive evidence-based information on natural childbirth and alternative methods of pain control, as well as the risks and indications for CS.

Treatment of posttraumatic stress disorder following childbirth

Aim: The aim of this systematic review is to give an overview of the literature on treatment options for posttraumatic stress disorder (PTSD) following childbirth and to assess their efficacy.Method: PubMed, Embase, Web of Science, Cochrane and PsycINFO were searched using "PTSD", "childbirth" and "therapy" as terms for studies in English language published between 2000 and 2017. Additional studies were identified by checking reference lists. Studies were included when presence of PTSD was confirmed prior to treatment and childbirth was the traumatic event focused on. All studies were reviewed on sample size, study design, used instruments, sample characteristics, type of treatment and the result of treatment regarding PTSD (symptoms).Results: Six studies met the inclusion criteria. One study on debriefing, three studies on cognitive behavioral therapy (CBT) and two studies on eye movement desensitization and reprocessing (EMDR) were identified. Both EMDR and CBT appear to be promising therapies for PTSD following childbirth. Debriefing seems to be beneficial when women request it themselves.Conclusions: EMDR and CBT seem to be effective as therapy for PTSD following childbirth. However, evidence is still limited and more controlled trials are needed to draw conclusive results.

The characteristics and prevalence of phobias in pregnancy

OBJECTIVE

The primary objective was to estimate the population prevalence of specific phobias (including pregnancy related specific phobias) and associated mental disorders. The secondary objective was to investigate the effectiveness of routinely collected screening tools (depression and anxiety screens, Whooley and GAD-2 respectively) in identifying specific phobias. Specific phobias are the most common anxiety disorder to occur during pregnancy, but studies on prevalence and clinical correlates of specific phobias, including pregnancy related specific phobias are lacking.

DESIGN

Cross-sectional survey using a two-phase sampling design stratified according to being positive or negative on the Whooley questions routinely asked by midwives. Approaching all whooley positive women and drawing a random sample of Whooley negative women. Sampling weights were used to account for the bias induced by the stratified sampling.

PARTICIPANTS

545 pregnant women attending their first antenatal appointment. Language interpreters were used where required.

SETTING

Inner-city maternity service, London, UK.

MEASUREMENTS

The Structured Clinical Interview for DSM-IV Axis I Mental Disorders were administered to assess mental disorders and 544 women responded to the anxiety module on specific phobias.

RESULTS

The maternity population prevalence estimate for specific phobias was 8.4% (95%CI: 5.8-12.1%) and for pregnancy related phobias was 1.5% (95%CI: 0.6-3.7%), most of which were needle phobias. The prevalence estimate of tokophobia was 0.032% (95%CI: 0.0044-0.23%). Over half (52.4%) the women with specific phobias had comorbid mental disorders. Routinely administered screening tools (Whooley and GAD-2) were not helpful in identifying phobias.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Phobias in pregnancy are common but pregnancy related phobias are rare, particularly tokophobia. As routinely administered screening tools were not helpful in identifying phobias, other indicators could be considered, such as avoidance of blood tests and requests for caesarean sections.

Maternal reasons for requesting planned cesarean section in Norway: a qualitative study

Background

Pregnant women who request a cesarean section in the absence of obstetric indication have become a highly debated issue in academic as well as popular literature. In order to find adequate, targeted treatment and preventive strategies, we need a better understanding of this phenomenon. The aim of this study is to provide a qualitative exploration of maternal requests for a planned cesarean section in Norway, in the absence of obstetric indications.

Methods

A descriptive qualitative study was conducted consisting of 17 semi-structured, in-depth interviews with women requesting cesarean section and six focus group discussions with 20 caregivers (nine midwives, 11 obstetricians) working at a university hospital in Norway. Data were analyzed with Systematic Text Condensation, a method for thematic cross-case analysis.

Results

Fear of birth emerged most commonly as a result of a previous traumatic birth experience that prompted a preference for a planned cesarean to avoid a repetition of the trauma. For some women in our study, postnatal care and the puerperal period were their crucial past experiences, and giving birth by planned cesarean was seen as a way to ensure mental rather than physical capability to care for the expected child after birth. Others were under the impression of being at high risk for an emergency C-section, and requesting a planned one was based on their perceived risk. Such perceptions included having a narrow pelvis, hereditary factors or previous birth outcomes. Some primiparas requested a planned cesarean based on a deep-seated fear since their early teens, accompanied by alienation towards the idea of giving birth. Some obstetricians participating in our study also experienced requests that lacked what they regarded as any well-grounded reason or significant fear.

Conclusions

Behind a maternal request for a planned cesarean section are various rationales and life experiences needing carefully targeted attention and health care. Previous births are an important driver; thus, maternally requested cesareans should be regarded partly as an iatrogenic problem.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2250-6) contains supplementary material, which is available to authorized users.

"It Can't Be Like Last Time" - Choices Made in Early Pregnancy by Women Who Have Previously Experienced a Traumatic Birth

Background: A significant number of women experience childbirth as traumatic. These experiences are often characterized by a loss of control coupled with a perceived lack of support and inadequate communication with health care providers. Little is known about the choices women make in subsequent pregnancy(s) and birth(s), or why they make these choices. This study aimed to understand these choices and explore the reasons behind them. Methods: A longitudinal grounded theory methods study involving nine women was conducted. Over half of the participants had a formal diagnosis of post-traumatic stress disorder (PTSD) and/or PND related to the previous birth. Interviews were carried out at three timepoints perinatally. These findings are from the first interviews at 12-20 weeks. Results: From the first days of pregnancy, this cohort of women were focused on concerns that this birth would be a repeated traumatic experience. The women were deliberately searching out and analyzing information about their choices in this pregnancy and birth, and making plans which had two aims; firstly to avoid a repeat of their previous birth experience and secondly to avoid a loss of control to other people during the birth. The women considered a range of birth choices, from elective cesareans to freebirth. Some women felt well supported by those around them, including care providers, partners, friends, and family. Others did not feel supported and were anticipating conflict in trying to assert their birth choices. Many early relationships with healthcare professionals were characterized by fear and mistrust. Discussion: If women who have previously experienced a traumatic birth become pregnant again, they have a strong desire to avoid a repeat experience and to feel in control of their birth choices. Access to robust information appears to help reduce uncertainty and arm women in their discussions with professionals. Similarly making plans and seeking to have them agreed with care providers at an early stage is used a way to reduce the risk of having a further traumatic experience. Implications for practice include supporting women in formulating and confirming pregnancy and birth plans at an early stage to reduce uncertainty and foster a sense of control.

Fear of Childbirth, Postpartum Depression, and Birth-Related Variables as Predictors of Posttraumatic Stress Disorder After Childbirth

BACKGROUND

Childbirth may be a significant cause of postpartum posttraumatic stress disorder (PTSD) in women.

AIMS

The objective of this study is to examine the effect of fear of childbirth, postpartum depression, and certain birth-related variables on postpartum PTSD.

METHODS

This study is a cross-sectional study. The study was carried out in a maternity hospital nonstress unit between December 1, 2015, and February 29, 2016. Three hundred and one pregnant women who met the criteria for inclusion in the study made up the research sample.

RESULTS

Fear of childbirth and postpartum depression significantly and positively predicted the level of posttraumatic stress after childbirth (β = 0.17, p < .01; β = 0.68, p < .001). Fear of childbirth explains 3% of the total variance in posttraumatic stress (R²  = .03, adjusted R²  = .02, F = 7.141, p < .01), while postpartum depression explains 47% of it (R²  = .47, adjusted R²  = .46, F = 196.35, p < .001). Satisfaction with the attitudes of the medical staff during childbirth, defining the childbirth experience, and the state of experiencing postpartum problems by the mother are significant predictors of postpartum posttraumatic stress (β = -0.21, p < .01; β = -0.14, p < .05; β = 0.17, p < .01). When these three variables are addressed together, they explain 14% of the total variance (R²  = .14, adjusted R²  = .13, F = 9.33, p < .001).

LINKING EVIDENCE TO ACTION

Postpartum PTSD is a situation that must be carefully emphasized in terms of maternal, baby, and family health. For this reason, it is necessary to evaluate postpartum PTSD more quickly and objectively, and healthcare providers have major duties in this respect.

Trauma and fear in Australian midwives

BACKGROUND

Relatively little is known about the extent of trauma and birth-related fear in midwives and how this might affect practice.

AIM

(1) Determine prevalence of birth related trauma and fear in midwives and associations with midwives' confidence to advise women during pregnancy of their birth options and to provide care in labour. (2) Describe midwives' experiences of birth related trauma and/or fear.

METHOD

A mixed methods design. A convenience sample of midwives (n=249) completed an anonymous online survey. Descriptive and inferential statistics were used to analyse the quantitative data. Latent content analysis was used to extrapolate meaning from the 170 midwives who wrote about their experiences of personal and/or professional trauma.

RESULTS

The majority of midwives (93.6%) reported professional (n=199, 85.4%) and/or personal (n=97, 41.6%) traumatic birth experiences. Eight percent (n=20) reported being highly fearful of birth. Trauma was not associated with practice concerns but fear was. Midwives categorised as having 'high fear' reported more practice concerns (Med 23.5, n=20) than midwives with 'low fear' (Med 8, n=212) (U=1396, z=-3.79, p<0.001, r=0.24). Reasons for personal trauma included experiencing assault, intervention and stillbirth. Professional trauma related to both witnessing and experiencing disrespectful care and subsequently feeling complicit in the provision of poor care. Feeling unsupported in the workplace and fearing litigation intensified trauma.

CONCLUSION

High fear was associated with lower confidence to support childbearing women. Fear and trauma in midwives warrants further investigation to better understand the impact on professional practice.

Support for pregnant women identified with fear of childbirth (FOC)/tokophobia - A systematic review of approaches and interventions

BACKGROUND

providing appropriate care for pregnant women with high or severe fear of childbirth (FOC) is a challenge in midwifery care today. FOC is associated with predisposing anamnestic factors, various sociodemographic and psychosocial characteristics, and may result in serious healthrelated consequences. It is therefore important to establish which interventions may increase a woman's faith in her own ability to cope with labour and birth.

AIM

to systematically identify and review studies examining interventions for relief of severe fear of childbirth in pregnancy and their underlying conceptual foundation.

METHODS

a systematic literature search was performed following Cochrane Collaboration and PRISMA Statement recommendations. Inclusion criteria were: studies including pregnant women diagnosed with high or severe FOC or who requested a caesarean section due to severe FOC, studies (regardless of design) observing the effect of an intervention addressing FOC, and studies published in English. Publications addressing anxiety or stress were excluded. 377 references were screened by title and abstract. The risk of bias was assessed.

FINDINGS

19 articles referring to 15 research projects were included in the analysis. The studies show heterogeneity regarding assessment methods, type, conceptualisation and application of interventions. There is evidence that both cognitive therapy sessions and a theory-based group psychoeducation with relaxation are effective interventions.

KEY CONCLUSIONS

despite methodological limitations, single or group psychoeducation sessions for nulliparous women or therapeutic conversation during pregnancy (in group or individual sessions) have the potential to strengthen women's self-efficacy and decrease the number of caesarean sections due to FOC. The theoretical validation of an intervention deepens the understanding of psychological processes in women coping with severe FOC.

IMPLICATIONS FOR PRACTICE

theory-based concepts of care for both antenatal and intrapartum support of pregnant women with high or severe FOC should be developed, piloted, tested, evaluated and implemented within the given healthcare system. Midwives need to be competent to address pregnant women's fears regarding labour and birth in antenatal care. The use of a valid assessment tool to identify the level of FOC in women, even if they do not raise the issue, is recommended in routine antenatal care so that appropriate expert support can be offered. A one-on-one conversation may be feasible for those women unwilling to fill in a questionnaire. Cooperative local networks between midwives, psychologists and obstetricians qualified in psychotherapy should be established to ensure timely and effective care for women with high or severe FOC.

The trauma of birth

The trauma of birth is an international concern for all childbearing women globally. Since changes in 1994 to the Diagnostic Statistical Manual that included childbirth as a potentially traumatic event, several clusters of researchers, particularly representing the Scandinavian countries, the United Kingdom, and Australia, have emerged. Their research findings appear in numerous publications; yet, what is known from these studies is based on a variety of methodological designs and differing measurement tools making it difficult to draw many firm conclusions (Ayers, 2004 ; Ayers, Joseph, Mc-Kenzie-McHarg, Slade, & Wijma, 2008 ). This review offers information obtained from frequently cited, current and seminal research studies describing the trauma of birth among women of the world.

Just another ordinary bad birth? A narrative analysis of first time mothers' traumatic birth experiences

A difficult birth experience can have long lasting psychological effects on both mother and baby and this study details four in-depth accounts of first time mothers who described their birth experience as traumatizing. Narrative analysis was used to record discrepancies between the ideal and the real and produced narrative accounts that highlighted how these mothers felt invisible and dismissed in a medical culture of engineering obstetrics. Participants also detailed how their birth experience could be improved and this is set in context alongside current recommendations in maternal health care and the complexities of delivering such care in UK health settings.