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

Relationship of domestic violence with pregnancy symptoms and pregnancy experience in Iranian pregnant women: a cross-sectional study

OBJECTIVE

Violence has had adverse effects on the physical and psychological dimensions of pregnant women. This study was conducted with the aim of determining the relationship of domestic violence with pregnancy symptoms and pregnancy experience.

DESIGN

In this cross-sectional study, pregnant women were selected through two-stage cluster sampling method. Data were collected using the domestic violence questionnaire of the WHO, pregnancy symptoms inventory (PSI) and pregnancy experience scale (PES). To determine the relationship between domestic violence with pregnancy symptoms and pregnancy experience, adjusted general linear model was used in multivariate analysis.

SETTING

Health centres in Urmia-Iran in 2022.

PARTICIPANTS

415 pregnant women.

RESULTS

The frequency of emotional, physical and sexual violence was 86.0%, 67.7% and 79.5%, respectively. The mean (SD) of PSI was 49.45 (14.38) with attainable score of 0-123 and PES including happiness and worry was 14.32 (6.48) and 16.21 (2.51) with attainable score of 0-30, respectively. Based on the adjusted general linear model, the mean score of PSI in women who experienced physical violence (mild (p<0.001) and moderate (p<0.001)); sexual violence (mild (p<0.001), moderate (p<0.001) and severe (p<0.001)); and emotional violence (mild (p<0.001), moderate (p=0.002) and severe (p<0.001)) was significantly higher than women without experiencing violence. The mean score of happiness during pregnancy in women who experienced physical violence (moderate (p=0.011)) and emotional violence (mild (p<0.001), moderate (p=0.002) and severe (p<0.001)) was significantly lower than women without experience of violence. Also, the mean score of worry scores in women with experience of sexual violence (mild (p=0.001) and moderate (p=0.012)) and emotional violence (mild (p<0.001), moderate (p<0.001)) and severe (p<0.001)) was significantly higher than women without experiencing violence.

CONCLUSION

Considering the relationship between violence and pregnancy symptoms and pregnancy experiences, it is necessary to use appropriate strategies to prevent violence in pregnant women.

Cognitive processing biases associated with fear of childbirth

Fear of childbirth (FOC) is a phobic-like response concerning the prospect of giving birth. FOC can have negative implications for women during pregnancy and can impact their birthing experience. Cognitive processing biases (e.g., difficulty disengaging from threatening information, interpreting ambiguous information as threatening, and preferentially recalling threatening content) have previously been found to maintain general anxiety and low mood. To date, there has been no research assessing these attention, interpretation, and memory biases and their relationship with FOC in pregnant women. Accordingly, in this cross-sectional study, participants who were at least 12 weeks pregnant (n = 116), recruited through a local hospital trust, completed tasks assessing attention (emotional Stroop task), interpretation (scrambled sentences test), and explicit memory (recognition task) biases with materials including FOC-related content. They also completed three separate measures of FOC and measures of low mood, general anxiety, worry, and rumination. We found that a negative interpretation bias (but not attention or explicit memory biases) was associated with higher levels of FOC. These findings indicate that women presenting with higher FOC are more likely to demonstrate negative interpretation biases for ambiguous information relating to childbirth, which may inform research developing interventions to support women presenting with FOC.

Previous negative experiences of healthcare reported by Swedish pregnant women with fear of birth - A mixed method study

BACKGROUND

Negative encounters in healthcare might affect women's health. During their reproductive life span, women are exposed to various health examinations, and have reported disrespectful care and obstetric violence. Such experiences might be a basis for fear of birth.

AIM

to explore and describe the prevalence, associated factors and experiences of previous negative healthcare encounters in women with fear of birth.

METHODS

A cross-sectional mixed-method study of 335 pregnant women with fear of birth. Data were collected by a questionnaire in mid-pregnancy, which included socio-demographic and obstetric background data as well as a question about the occurrence of previous negative experiences in healthcare.

RESULT

A previous negative experience of healthcare was found in 189 women (56.6%). The analysis of the women's comments regarding what caused their negative experiences generated three themes: disrespectful treatment and no one listened; painful, inadequate, or improper care; and impact of other people's stories.

CONCLUSION

This study showed that previous negative experiences in healthcare were common in women with fear of birth and the content of the encounters could be summarised as disrespectful care and obstetric violence. Women's previous encounters in healthcare might be an underlying reason for fear of birth and should be investigated. It is, therefore, of utmost importance to listen to women and their narratives in order to establish a trustful relationship and promote evidence-based, women-centred, respectful care, which is urgently needed.

The impact of midwifery continuity of care on maternal mental health: A narrative systematic review

BACKGROUND

Systematic reviews have shown that midwifery continuity of care programs lead to improvements in birth outcomes for women and babies, but no reviews have focused specifically on the impact of midwifery continuity of care on maternal mental health outcomes.

OBJECTIVE

To systematically review the available evidence on the impact of midwifery continuity of care on maternal mental health during the perinatal period.

METHOD

A systematic search of published literature available through to March 2021 was conducted. A narrative approach was used to examine and synthesise the literature.

RESULTS

The search yielded eight articles that were grouped based on the mental health conditions they examined: fear of birth, anxiety, and depression. Findings indicate that midwifery continuity of care leads to improvements in maternal anxiety/worry and depression during the perinatal period.

CONCLUSION

There is preliminary evidence showing that midwifery continuity of care is beneficial in reducing anxiety/worry and depression in pregnant women during the antenatal period. As the evidence stands, midwifery continuity of care may be a preventative intervention to reduce maternal anxiety/worry and depression during the perinatal period.

Identifying women with fear of childbirth with the Dutch Fear of Birth Scale and its added value for consultations

OBJECTIVES

Determine whether the Fear of Birth Scale (FOBS) is a useful screening instrument for Fear of Childbirth (FoC) and examine the potential added value of screening by analyzing how often pregnant women discuss their FoC during consultation.

METHODS

This cross-sectional survey study included nulliparous pregnant women of all gestational ages, recruited via the internet, hospital and midwifery practices. The online questionnaires included the FOBS and Wijma Delivery Expectations Questionnaire version A (W-DEQ A). The latter was used as golden standard for assessing FoC (cutoff: ≥85).

RESULTS

Of the 364 included women, 67 (18.4%) had FoC according to the W-DEQ A. Using the FOBS with a cutoff score of ≥49, the sensitivity was 82.1% and the specificity 81.1%, with 111 (30.5%) women identified as having FoC. Positive predictive value was 49.5% and negative predictive value 95.3%. Of the women with FoC (FOBS ≥49), 68 (61.3%) did not discuss FoC with their caregiver.

CONCLUSION

The FOBS is a useful screening instrument for FoC. A positive score must be followed by further assessment, either by discussing it during consultation or additional evaluation with the W-DEQ A. The majority of pregnant women with FoC do not discuss their fears, underscoring the need for screening.

The role of women's emotional profiles in birth outcome and birth experience

OBJECTIVE

The aim was to investigate birth outcome and birth experience in relation to women's emotional health. An additional aim was to explore the relationship between emotional health, continuity with a known midwife, and the birth experience.

METHODS

A prospective longitudinal cohort study of 243 women enrolled in a continuity of care project in a rural area in Sweden. Profiles were constructed from instruments measuring depressive symptoms, worries, fear of birth, and sense of coherence. Antenatal and birth records and questionnaires were used to collect data.

RESULT

Women were categorized into two cluster profiles: "emotionally healthy" vs. "emotionally unhealthy". Women in the "emotionally unhealthy" cluster had a less positive birth experience (p = 0.006). The total score of the Childbirth Experience Questionnaire was highest in women who had had a known midwife assisting at birth. Babies born to women in the "emotionally unhealthy" cluster were more likely to have a severe neonatal diagnosis.

CONCLUSION

There were few differences in birth outcome between the clusters, while there were explicit differences in the childbirth experience. Having a known midwife is important to warrant women a more positive childbirth experience. Screening with validated instruments during antenatal care could be a first step to further investigate women's emotional well-being and provide targeted psychosocial support.

Is it Necessary to Evaluate Fear of Childbirth in Pregnant Women? A Scoping Review

OBJECTIVE

 To review concepts, definitions, and findings about fear of childbirth (FOC).

METHODS

 A bibliographic review was carried out through the main scientific databases in 2020.

RESULTS

 All 32 articles considered potentially relevant were analyzed. A recent study suggests that the global prevalence of FOC can reach up to 14%. Factors such as parity, gestational age, previous birth experience, age and nationality of the woman seem to influence FOC.

CONCLUSION

 Fear of childbirth could be related to an increased risk of adverse obstetric outcomes such as maternal request for cesarean delivery, preterm birth, prolonged labor, postpartum depression, and post-traumatic stress. These evidence highlight the importance of the discussion regarding this topic.

The impact of yoga on fear of childbirth and childbirth self-efficacy among third trimester pregnants

BACKGROUND

This study was conducted to determine the effect of yoga practice on fear of childbirth and childbirth self-efficacy.

MATERIALS AND METHODS

This study was performed in a quasi-experimental model with pretest and post-test control groups. The participants of the study were women who applied to a pregnancy education class at a hospital. Ninety women participated in the study. The data used in the study were collected using the Individual Information Form, the Wijma Delivery Expectation/Experience Scale (Version A), and the Childbirth Self-Efficacy Scale.

RESULTS

After participating in yoga practice, the pregnant women in the experimental group exhibited decreased fear of childbirth and increased childbirth self-efficacy (p < .05). On the other hand, the pregnant women in the control group displayed increased fear of childbirth and decreased childbirth self-efficacy (p < .05).

CONCLUSION

Based on the results of this study, yoga practice reduces fear of childbirth and significantly increases childbirth self-efficacy.

Interventions for fear of childbirth including tocophobia

BACKGROUND

Many women experience fear of childbirth (FOC). While fears about childbirth may be normal during pregnancy, some women experience high to severe FOC. At the extreme end of the fear spectrum is tocophobia, which is considered a specific condition that may cause distress, affect well-being during pregnancy and impede the transition to parenthood. Various interventions have been trialled, which support women to reduce and manage high to severe FOC, including tocophobia.

OBJECTIVES

To investigate the effectiveness of non-pharmacological interventions for reducing fear of childbirth (FOC) compared with standard maternity care in pregnant women with high to severe FOC, including tocophobia.

SEARCH METHODS

In July 2020, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. We contacted researchers of trials which were registered and appeared to be ongoing.

SELECTION CRITERIA

We included randomised clinical trials which recruited pregnant women with high or severe FOC (as defined by the individual trial), for treatment intended to reduce FOC. Two review authors independently screened and selected titles and abstracts for inclusion. We excluded quasi-randomised and cross-over trials.

DATA COLLECTION AND ANALYSIS

We used standard methodological approaches as recommended by Cochrane. Two review authors independently extracted data and assessed the studies for risk of bias. A third review author checked the data analysis for accuracy. We used GRADE to assess the certainty of the evidence. The primary outcome was a reduction in FOC. Secondary outcomes were caesarean section, depression, birth preference for caesarean section or spontaneous vaginal delivery, and epidural use.

MAIN RESULTS

We included seven trials with a total of 1357 participants. The interventions included psychoeducation, cognitive behavioural therapy, group discussion, peer education and art therapy. We judged four studies as high or unclear risk of bias in terms of allocation concealment; we judged three studies as high risk in terms of incomplete outcome data; and in all studies, there was a high risk of bias due to lack of blinding. We downgraded the certainty of the evidence due to concerns about risk of bias, imprecision and inconsistency. None of the studies reported data about women's anxiety. Participating in non-pharmacological interventions may reduce levels of fear of childbirth, as measured by the Wijma Delivery Expectancy Questionnaire (W-DEQ), but the reduction may not be clinically meaningful (mean difference (MD) -7.08, 95% confidence interval (CI) -12.19 to -1.97; 7 studies, 828 women; low-certainty evidence). The W-DEQ tool is scored from 0 to 165 (higher score = greater fear). Non-pharmacological interventions probably reduce the number of women having a caesarean section (RR 0.70, 95% CI 0.55 to 0.89; 5 studies, 557 women; moderate-certainty evidence). There may be little to no difference between non-pharmacological interventions and usual care in depression scores measured with the Edinburgh Postnatal Depression Scale (EPDS) (MD 0.09, 95% CI -1.23 to 1.40; 2 studies, 399 women; low-certainty evidence). The EPDS tool is scored from 0 to 30 (higher score = greater depression). Non-pharmacological interventions probably lead to fewer women preferring a caesarean section (RR 0.37, 95% CI 0.15 to 0.89; 3 studies, 276 women; moderate-certainty evidence).  Non-pharmacological interventions may increase epidural use compared with usual care, but the 95% CI includes the possibility of a slight reduction in epidural use (RR 1.21, 95% CI 0.98 to 1.48; 2 studies, 380 women; low-certainty evidence).

AUTHORS' CONCLUSIONS

The effect of non-pharmacological interventions for women with high to severe fear of childbirth in terms of reducing fear is uncertain. Fear of childbirth, as measured by W-DEQ, may be reduced but it is not certain if this represents a meaningful clinical reduction of fear. There may be little or no difference in depression, but there may be a reduction in caesarean section delivery. Future trials should recruit adequate numbers of women and measure birth satisfaction and anxiety.

The experiential knowledge of migrant women about vulnerability during pregnancy: A woman-centred mixed-methods study

PROBLEM

Within maternity care policies and practice, pregnant migrant women are regarded as a vulnerable population.

BACKGROUND

Women's experiential knowledge is a key element of woman-centred care but is insufficiently addressed in midwifery practice and research that involves migrant women.

AIM

To examine if pregnant migrant women's experiential knowledge of vulnerability corresponds with sets of criteria of vulnerability, and to explore how migrant women make sense of vulnerability during pregnancy.

METHODS

A sequential two-phased mixed-methods study, conducted in the Netherlands, integrating survey data of 89 pregnant migrant women and focus group data obtained from 25 migrant mothers - living in deprived areas according to the Dutch socio-economic index.

RESULTS

Criteria associated with vulnerability were reported by 65.2% of the participants and 62.9% of the participants reported adverse childhood experiences. On a Visual Analogue Scale, ranging from 0 (not vulnerable) to 10 (very vulnerable), participants self-reported sense of vulnerability showed a mean score of 4.2 (±2.56). Women's experiential knowledge of vulnerability significantly correlated with the mean sum score of clinical criteria of vulnerability (r .46, p .002) and with the mean sum score of adverse childhood experiences (r .48, p<.001). Five themes emerged from the focus group discussions: "Look beyond who you think I am and see and treat me for who I really am", "Ownership of truth and knowledge", "Don't punish me for being honest", "Projection of fear" and "Coping with labelling".

CONCLUSION

Pregnant migrant women's experiential knowledge of vulnerability is congruent with the criteria. Calling upon experiential knowledge is an attribute of the humane woman-midwife relationship.

Women's worries during pregnancy; a cross-sectional survey using the Cambridge Worry Scale in a rural area with long distance to hospital

BACKGROUND

Worries are common during pregnancy, but there is sparse knowledge of worries when the distance to hospital is long.

AIM

To assess the extent and content of worries during pregnancy. Another aim was to evaluate the psychometric properties of the Swedish version of the Cambridge Worry Scale.

METHOD

Cross-sectional study of 280 women recruited to a continuity project and completed a questionnaire in mid pregnancy.

RESULT

Women were most worried about something being wrong with the baby, giving birth and the risk of miscarriage. Women also reported worries about giving birth on the road or in the car. Two domains of the Cambridge Worry scale were identified; Socio-medical and health aspects and Socio-economic and relationship aspects. Women with high fear and depressive symptoms were most at risk for major worries.

CONCLUSION

Worries during pregnancy were mainly related to issues about pregnancy and birth, and specifically, to long distance to the labour ward. Women with depressive symptoms and fear of birth showed the highest levels of worries. When a woman expresses worries in connection to labour and birth, caregivers must be sensitive to the presence of underling fears or depressive symptoms and act to refer women to treatment or support.

The Perceived Health Needs of Primiparous Mothers Referring to Primary Health Care Centers: A Qualitative Study

Background

Since the first step in meeting the health needs of primiparous women involves understanding their conditions, the present study aimed to determine the health needs of primiparous women from their own viewpoints.

Methods

This study had a qualitative approach based on the conventional qualitative content analysis method, in which the purposive sampling method was used. Data were collected by semi-structured interviews. Data saturation was achieved by interviewing 12 participants. To ensure the study was rigorous, the four criteria of credibility, dependability, confirmability, and transferability were taken into account.

Results

The findings of this study consisted of 150 codes, 19 subcategories, and 6 categories, as follows: 1) the intense need for social support, 2) the need for prior preparation for pregnancy, 3) fears and worries, 4) the necessity of the availability of the needed infrastructures and requirements in the health center, 5) falling in love with the baby, and 6) seeking information from appropriate sources.

Conclusion

The present study showed that primiparous women need to receive more social and psychological support from family members and healthcare workers and that it is essential to improve the available infrastructures and services in healthcare centers and to provide the needed counseling to pregnant mothers to enable them to go through the pregnancy period smoothly.

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.

A continuity of care project with two on-call schedules: Findings from a rural area in Sweden

BACKGROUND

In many countries, various continuity models of midwifery care arrangements have been developed to benefit women and babies. In Sweden, such models are rare.

AIM

To evaluate two on-call schedules for enabling continuity of midwifery care during labour and birth, in a rural area of Sweden.

METHOD

A participatory action research project where the project was discussed, planned and implemented in collaboration between researchers, midwives and the project leader, and refined during the project period. Questionnaires were collected from participating women, in mid pregnancy and two months after birth.

RESULT

One of the models resulted in a higher degree of continuity, especially for women with fear of birth. Having a known midwife was associated with higher satisfaction in the medical (aOR 2.02 (95% CI 1.14-4.22) and the emotional (aOR 2.05; 1.09-3.86) aspects of intrapartum care, regardless of the model.

CONCLUSION

This study presented and evaluated two models of continuity with different on-call schedules and different possibilities for women to have access to a known midwife during labour and birth. Women were satisfied with the intrapartum care, and those who had had a known midwife were the most satisfied. Introducing a new model of care in a rural area where the labour ward recently closed challenged both the midwives' working conditions and women's access to evidence-based care.

Women's experiences of interventions for fear of childbirth in the perinatal period: A meta-synthesis of qualitative research evidence

ISSUE

Fear of childbirth (FOC) can be debilitating, impacting women's lives in pregnancy, the puerperium and beyond. Research investigated various interventions for FOC in the perinatal period, but there been no synthesis of the experiences of women who engaged with these interventions, which would inform clinical practice guidance and the development of future interventions.

AIM

To conduct a review and synthesis of qualitative studies of interventions for fear of childbirth in the perinatal period and women's experiences of them.

METHODS

A meta-synthesis was performed to examine all relevant qualitative studies describing women's experiences of interventions for FOC, in all languages. A comprehensive search of relevant databases from 1978 to 2019 was conducted. In total, following appraisal, seven qualitative studies were eligible for inclusion. The findings were integrated using thematic synthesis for the final stages in the thematic analysis.

FINDINGS

One overarching theme "Ownership of Childbirth" and three analytical themes "Facing the fear", "Feeling empowered", "Managing the fear with a sense of security" were generated through the synthesis. There were no studies outside of Scandinavia located.

DISCUSSION

This meta-synthesis provides a new way to describe the process of moving from fear to "Ownership of childbirth". The first step in the process appears to be acknowledging and identifying the individual's fears. Women can be empowered to self-manage FOC but may be influenced by external factors such as the support of partners and staff.

CONCLUSION

These findings provide evidence to inform the development of future interventions for FOC and highlight the need for further qualitative research globally.

A comparison of the Fear of Childbirth Scale with the Tilburg Pregnancy Distress Scale to identify childbirth-related fear in a sample of Dutch pregnant women: a diagnostic accuracy comparative cross-sectional study

BACKGROUND

Because of the considerable negative effects of women's childbirth-related anxiety, fear and worries, and the time constraints that midwives perceive to assess women's antenatal emotional wellbeing, it is important that midwives can identify women with a more severe fear of birth with an easy to administer, validated tool.

OBJECTIVE

To investigate the ability of the two-item Fear of Childbirth Scale (FOBS) to discriminate between pregnant women with and without birth-related fear, compared with the 16-item Tilburg Pregnancy Distress Scale (TPDS).

METHODS

A diagnostic accuracy comparative cross-sectional study was performed, comparing two screening tests. Sensitivity, specificity, positive and negative predictive values and accuracy and discriminant property of the FOBS were determined and compared with the TPDS and with the negative affect 11-items TPDS (TPDS-NA) subscale. The TPDS and TPDS-NA were treated as reference standard to establish the discriminative potential of the FOBS for the presence or absence of antenatal birth-related fear.

PARTICIPANTS

A sample of 396 Dutch women with uncomplicated pregnancies.

RESULTS

When compared with the 16-items TPDS, the FOBS showed a higher specificity (95%) than sensitivity (70%) to detect fear of childbirth. The FOBS items had a good predictive ability for fear and worries about the forthcoming birth (79%) and a conclusive ability for negative case-finding (92%). The FOBS showed good accuracy (89%). The FOBS discriminated women who were or were not classified as being fearful according to the TPDS (AUC .86). When compared with the 11 items TPDS-NA subscale, the FOBS validity and accuracy decreased: sensitivity: 51%; specificity 92%; positive predictive ability 65%; negative predictive ability 88%; accuracy 83%; AUC .82.

CONCLUSION

When compared with the 16-items TPDS, the two-item FOBS shows to be an accurate tool for identifying the presence of antenatal birth-related fear in a sample of Dutch women with uncomplicated pregnancies.

Fear of birth-A prospective cohort study of primigravida in the UK

OBJECTIVE

An increase in the number of women who have fear of birth [FOB] has been reported globally; yet, how these women are identified varies. This study aimed to identify the most effective way of measuring FOB in clinical practice.

DESIGN

This paper reports on a prospective cohort study; a core element of an explanatory mixed-methods study. This element explored the appropriateness of measures of anxiety (biomarkers and validated questionnaires) and observed any relationship between anxiety levels and clinical outcomes.

PARTICIPANTS

A purposive sampling strategy was used. One hundred and forty-eight primigravida, during the 1st trimester, in two tertiary maternity units in England were included.

METHODS

Demographic and baseline data were collected from participants in the first trimester of pregnancy along with FOB scores, and a saliva sample to measure cortisol level. In the third trimester, a second FOBS score, and saliva sample were collected, and the Personal Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) were administered to measure depression and anxiety respectively.

FINDINGS

The FOBS was completed by 148 women in the first trimester and 80 in the third. Using a cut-off of 54, 30/148 (20%) women had a FOB in the first trimester; 21/80 (26%) had a FOB in the third trimester, 15 (19%) of whom also had a FOB in the first. Compared with the first trimester, 51/80 women showed an increase in FOBS score, with 14 scores increasing above and 8 scores decreasing below the cut-off of 54. FOBS scores were not correlated with salivary cortisol in either trimester (first trimester Spearman's ρ=0.08, p = 0.354, n = 144; third trimester ρ=0.12, p = 0.309, n = 71) but they were correlated with PHQ-9 and GAD-7 scores in the third trimester (PHQ-9 ρ=0.53, p = 0.010, n = 23; GAD-7 ρ=0.45, p = 0.033, n = 23) although not sufficiently high enough to demonstrate convergent validity against those measures of depression and anxiety. They were also associated with a previous history of depression but only in the first trimester (p = 0.011). FOBS scores showed considerable variability and a high measurement error, indicating a need for further refinement and psychometric testing.

CONCLUSION

The FOBS is a potentially effective way of measuring FOB in clinical practice and research, but it requires refining. Scores are not related to salivary cortisol levels but are correlated with validated scores for anxiety and depression. An enhanced version of the FOBS could be used in clinical practice to measure FOB.

Potential mechanisms in fear of birth: The role of pain catastrophizing and intolerance of uncertainty

BACKGROUND

Although many pregnant women experience fear, worry, or anxiety relating to the upcoming birth, little is known regarding the psychological mechanisms contributing to these experiences. In this study, we wanted to take a first step in trying to identify mechanisms of potential interest. The objective of this cross-sectional study was thus to investigate pain catastrophizing, intolerance of uncertainty, positive worry beliefs, and cognitive avoidance as potential mechanisms predicting fear of birth among pregnant women.

METHODS

A sample of 499 pregnant women, recruited in antenatal health care settings in 2 Swedish regions, completed the Fear of Birth Scale, along with measurements of the mechanisms of interest. Linear and logistic hierarchical regression analyses were used to investigate the extent to which pain catastrophizing, intolerance of uncertainty, positive worry beliefs, and cognitive avoidance predicted fear of birth, both as a continuous and a dichotomous measure.

RESULTS

Logistic regression analysis showed high levels of pain catastrophizing and intolerance of uncertainty to be the best predictors of fear of birth, OR 3.49 (95% CI 2.17-5.61) and OR 3.25 (95% CI 2.00-5.27), respectively. Positive beliefs about worry and cognitive avoidance were both correlated with fear of birth as a continuous measure, but did not contribute to the logistic regression model.

CONCLUSIONS

Pain catastrophizing and intolerance of uncertainty were the most evident predictors of fear of birth. Although preliminary, the findings suggest that interventions targeting catastrophic cognitions and intolerance of uncertainty might be relevant to psychological treatment for fear, worry, or anxiety relating to giving birth.

Effects of the birthing room environment on vaginal births and client-centred outcomes for women at term planning a vaginal birth: BE-UP, a multicentre randomised controlled trial

Background

Caesarean sections (CSs) are associated with increased risk for maternal morbidity and mortality. The recommendations of the recently published German national health goal ‘Health in Childbirth’ (Gesundheit rund um die Geburt) promote vaginal births (VBs).

This randomised controlled trial (RCT) evaluates the effects of a complex intervention pertaining to the birth environment, based on the sociology of technical artefacts and symbolic interactionism. The intervention is intended to foster an upright position and mobility during labour, which lead to a higher probability of VB.

Methods/design

This study is an active controlled superiority trial with a two-arm parallel design. The complex intervention involves making changes to the birthing room to encourage an upright position and mobility of women in labour and to relax them, which may help them to cope with labour and may increase self-determination. This may result in more VBs. Included in the study are primiparae and multiparae with a singleton foetus in cephalic presentation at term planning a VB. According to the sample size calculation, 3800 women in 12 obstetrical units are to be included. Randomisation will be performed centrally and controlled by an independent coordination centre. Blinding of participants and staff is not possible. Key outcomes are VB, episiotomy, perineal tears, epidural analgesia, critical outcome of newborn at term and maternal self-determination during birth. Additionally, a health economic evaluation will be performed.

Discussion

This is the first adequately powered multicentre RCT examining the effect of a redesigned birthing room on the probability of a VB and patient-centred physical and emotional outcomes. An increase in the number of VBs by 5% from a baseline of 74% to 79% would result in 21,000 women per year experiencing a VB rather than a CS in Germany. Expected benefits are greater self-determination during labour, improved physical and emotional client-centred outcomes, fewer medical interventions and a reduction in health-care costs.

Trial registration

German Clinical Trials Register (Deutsches Register Klinischer Studien), DRKS00012854. Registered on 7 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2979-7) contains supplementary material, which is available to authorized users.

Women with fear of childbirth might benefit from having a known midwife during labour

AIM

Having a known midwife at birth is valued by women across the world, however it is unusual for women with fear of childbirth to have access to this model of care. The aim of this study was to describe the prevalence and factors related to having access to a known midwife for women referred to counseling due to childbirth fear. We also wanted to explore if women's levels of childbirth fear changed over time.

METHODS

A pilot study of 70 women referred to counseling due to fear of birth in 3 Swedish hospitals, and where the counseling midwife, when possible, also assisted during labour and birth.

RESULTS

34% of the women actually had a known midwife during labour and birth. Women who had a known midwife had significantly more counseling visits, they viewed the continuity of care as more important, were more satisfied with the counseling and 29% reported that their fear disappeared. Fear of birth decreased significantly over time for all women irrespective of whether they were cared for in labour by a known midwife or not.

CONCLUSIONS

Although the women in the present study had limited access to a known midwife, the results indicate that having a known midwife whom the women met on several occasions made them more satisfied with the counseling and had a positive effect on their fear. Building a trustful midwife-woman relationship rather than counseling per se could be the key issue when it comes to fear of birth.

Comparing Internet-Based Cognitive Behavioral Therapy With Standard Care for Women With Fear of Birth: Randomized Controlled Trial

BACKGROUND

Although many pregnant women report fear related to the approaching birth, no consensus exists on how fear of birth should be handled in clinical care.

OBJECTIVE

This randomized controlled trial aimed to compare the efficacy of a guided internet-based self-help program based on cognitive behavioral therapy (guided ICBT) with standard care on the levels of fear of birth in a sample of pregnant women reporting fear of birth.

METHODS

This nonblinded, multicenter randomized controlled trial with a parallel design was conducted at three study centers (hospitals) in Sweden. Recruitment commenced at the ultrasound screening examination during gestational weeks 17-20. The therapist-guided ICBT intervention was inspired by the Unified protocol for transdiagnostic treatment of emotional disorders and consisted of 8 treatment modules and 1 module for postpartum follow-up. The aim was to help participants observe and understand their fear of birth and find new ways of coping with difficult thoughts and emotions. Standard care was offered in the three different study regions. The primary outcome was self-assessed levels of fear of birth, measured using the Fear of Birth Scale.

RESULTS

We included 258 pregnant women reporting clinically significant levels of fear of birth (guided ICBT group, 127; standard care group, 131). Of the 127 women randomized to the guided ICBT group, 103 (81%) commenced treatment, 60 (47%) moved on to the second module, and only 13 (10%) finished ≥4 modules. The levels of fear of birth did not differ between the intervention groups postintervention. At 1-year postpartum follow-up, participants in the guided ICBT group exhibited significantly lower levels of fear of birth (U=3674.00, z=-1.97, P=.049, Cohen d=0.28, 95% CI -0.01 to 0.57). Using the linear mixed models analysis, an overall decrease in the levels of fear of birth over time was found (P≤ .001), along with a significant interaction between time and intervention, showing a larger reduction in fear of birth in the guided ICBT group over time (F_1,192.538=4.96, P=.03).

CONCLUSIONS

Fear of birth decreased over time in both intervention groups; while the decrease was slightly larger in the guided ICBT group, the main effect of time alone, regardless of treatment allocation, was most evident. Poor treatment adherence to guided ICBT implies low feasibility and acceptance of this treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02306434; https://clinicaltrials.gov/ct2/show/NCT02306434 (Archived by WebCite at http://www.webcitation.org/70sj83qat).

Caseload midwifery for women with fear of birth is a feasible option

OBJECTIVE

Continuity with a known midwife might benefit women with fear of birth, but is rare in Sweden. The aim was to test a modified caseload midwifery model of care to provide continuity of caregiver to women with fear of birth.

METHODS

A feasibility study where women received antenatal and intrapartum care from a known midwife who focused on women's fear during all antenatal visits. The study was performed in one antenatal clinic in central Sweden and one university hospital labor ward. Data was collected with questionnaires in mid and late pregnancy and two months after birth. The main outcome was fear of childbirth.

RESULT

Eight out of ten women received all antenatal and intrapartum care from a known midwife. The majority had a normal vaginal birth with non-pharmacological pain relief. Satisfaction was high and most women reported that their fear of birth alleviated or disappeared.

CONCLUSION

Offering a modified caseload midwifery model of care seems to be a feasible option for women with elevated levels of childbirth fear as well as for midwives working in antenatal clinics as it reduces fear of childbirth for most women. Women were satisfied with the model of care and with the care provided.

A randomized controlled study comparing internet-based cognitive behavioral therapy and counselling by standard care for fear of birth - A study protocol

Fear of birth is a concern that requires evidence based treatment. The aim of this study is to present the protocol of a randomized controlled multi-center trial to compare internet-based cognitive therapy with counseling as standard care for pregnant women reporting fear of birth. Participants will be recruited in mid-pregnancy. Women who score 60 or above on the Fear of Birth Scale will be offered to participate in this study. Data will be collected by questionnaires including validated instruments at baseline and follow-ups at gestational weeks 30 and 36, two months and one year after birth. The primary outcome will be level of fear of birth measured with the Fear of Birth Scale at 36 weeks of gestation. Secondary outcome measures are level of fear of birth at two months and one year after giving birth, preferences for mode of birth, requests for elective cesarean section, compliance and satisfaction with treatment and birth outcomes. A power calculation based on a 20% reduction of fear implies that approximately 200 will be included in the trial. The study outlined in this protocol will be the first randomized controlled trial comparing internet-based cognitive therapy with counseling for women reporting fear of birth. An effective treatment may result in better overall health for women with fear of birth and a reduction in cesarean sections for non-medical reasons. Evidence regarding treatment options of fear of birth will also provide a greater choice for women.

Pregnancy related anxiety and general anxious or depressed mood and the choice for birth setting: a secondary data-analysis of the DELIVER study

Background

In several developed countries women with a low risk of complications during pregnancy and childbirth can make choices regarding place of birth. In the Netherlands, these women receive midwife-led care and can choose between a home or hospital birth. The declining rate of midwife-led home births alongside the recent debate on safety of home births in the Netherlands, however, suggest an association of choice of birth place with psychological factors related to safety and risk perception. In this study associations of pregnancy related anxiety and general anxious or depressed mood with (changes in) planned place of birth were explored in low risk women in midwife-led care until the start of labour.

Methods

Data (n = 2854 low risk women in midwife-led care at the onset of labour) were selected from the prospective multicenter DELIVER study. Women completed the Pregnancy Related Anxiety Questionnaire-Revised (PRAQ-R) to assess pregnancy related anxiety and the EuroQol-6D (EQ-6D) for an anxious and/or depressed mood.

Results

A high PRAQ-R score was associated with planned hospital birth in nulliparous (aOR 1.92; 95% CI 1.32–2.81) and parous women (aOR 2.08; 95% CI 1.55–2.80). An anxious or depressed mood was associated with planned hospital birth (aOR 1.58; 95% CI 1.20–2.08) and with being undecided (aOR 1.99; 95% CI 1.23–2.99) in parous women only. The majority of women did not change their planned place of birth. Changing from an initially planned home birth to a hospital birth later in pregnancy was, however, associated with becoming anxious or depressed after 35 weeks gestation in nulliparous women (aOR 4.17; 95% CI 1.35–12.89) and with pregnancy related anxiety at 20 weeks gestation in parous women (aOR 3.91; 95% CI 1.32–11.61).

Conclusion

Low risk women who planned hospital birth (or who were undecided) more often reported pregnancy related anxiety or an anxious or depressed mood. Women who changed from home to hospital birth during pregnancy more often reported pregnancy related anxiety or an anxious or depressed mood in late pregnancy. Anxiety should be adequately addressed in the process of informed decision-making regarding planned place of birth in low risk women.