The Fear of Childbirth: A Study in the North of Portugal

Abstract

Childbirth is a universal phenomenon and a meaningful experience that has the potential to trigger developmental transitions, stress, anxiety and/or fear, which, at times, can negatively impact future childbirth experiences. An exploratory and descriptive study was conducted aiming to identify the levels of fear experienced by pregnant women associated with childbirth and their main causes. A convenience sample was selected. Data collection were carried out in an outpatient obstetric hospital in the northern region of Portugal, between July 2010 and July 2012. To evaluate the intensity of fear of childbirth a visual analogic scale of 10 points was applied. Interviews were conducted in order to identify the main causes of fear. Ethical approval and informed consent were obtained. Regarding the level of fear, the majority (98%) of pregnant women had fear of childbirth, 60.2% reported moderate fear and 28% intense fear. Anxiety, primiparity and lack of knowledge related to birthing were also found to increase the fear of childbirth. Some of the main causes of fear identified were: complications during childbirth; pain/suffering; not knowing how to cope with pain; not able to give birth; baby with malformation/disease and/or suffering. Most women feel moderate or intense fear of childbirth and this is associated to well identified causes with high impact on the woman and family. To minimize the effects of fear, an early intervention has to be considered, including childbirth education classes where nurses can address and work women’s fear in order to minimize it and promote a more positive experience.

Keywords: Childbirth, Fear, nurses, pregnant women

Introduction

Pregnancy and childbirth are important events likely to cause developmental transitions and significant changes in the lives of women and families. These events can have a strong impact on their emotional balance, often triggering feelings of stress, anxiety, or fear.

The fear of childbirth can be triggered before or during pregnancy, being experienced during labour and delivery, with effects that can even linger afterwards. It influences daily life activities, the decision on a cesarean section delivery, and sometimes even the postponement of pregnancy (Melender, 2002; Hildingsson, Rådestad, Rubertsson & Waldenstrom, 2002; Bahl, Strachan & Murphy, 2004; Nilsson & Lundgren, 2009). During childbirth, fear leads to an increased perception of pain (Lang, Sorrell, Rodgers & Lebeck, 2006), potentially causing the woman to request an elective caesarean section (Saisto, Salmela-Aro, Nurmi, & Halmesmäki, 2001; Hildingsson et al., 2002; Saisto, & Halmesmäki. 2003; Bahl et al, 2004), prolong labour, and contribute to a negative birth experience and low satisfaction levels with childbirth (Larsen, O'Hara, Brewer, & Wenzel, 2001; Hildingsson et al., 2002; Johnson, & Slade 2002; Melender, 2002; Hofberg, & Ward, 2003; Saisto, & Halmesmäki, 2003; Wax Cartin, Pinette, & Blackstone, 2004; Waldenstrom, Lang et al, 2006; Hildingsson, 2008; Rouhe, Salmela-Aro, Halmesmäki, & Saisto, 2008; Nilsson & Lundgren, 2009; Fenwick, Gamble, Nathan, Bayes, & Hauck, 2009). Compared to available international data, evidence on the extent and causes of childbirth fear in the Portuguese population is limited. An exploratory and descriptive study was conducted aiming to identify the levels and the main causes of childbirth fear in pregnant women.

Methodology

An important aspect pertaining to the childbirth experience is fear, which can be defined as: "Feeling threatened, endangered or disturbed due to known or unknown causes, sometimes triggering a physiological response known as fight-or-flight" (ICN, 2011, p. 61).

In nulliparous women, the intense fear of childbirth is related to the perceived lack of control and self-confidence in their ability to safely bear a child. Some authors define this fear as "primary fear of childbirth or primary tokophobia" (Nieminen, Stephansson, & Ryding, 2009; Fenwick, Staff, Gamble, Creedy, & Bayes, 2010; Fenwick et al., 2013). According to Fenwick et al. (2013), in multiparous women, the cause of fear is often associated with a previous negative labour experience. The authors describe this as a "secondary fear" or "secondary tokophobia" (Zar, Wijma, & Wijma., 2001; Saisto et al, 2001; Hofberg, & Ward, 2003; Nilsson, Lundgren, Karlström, & Hildingsson, 2012; Fenwick et al, 2013).

Globally, the prevalence of fear associated with childbirth is estimated at around 20%. Of this, 6-10% of the women experience severe levels of fear, which influences their ability to expect a normal birth (Kjaergaard, Wijma, Dykes, & Alehagen, 2008). A study conducted by Lukasse et al. (2014) in six European countries shows that 11% (n=768) of all the women participants reported intense fear of childbirth, 11.4% were primiparous women and 11.0% multiparous women. In these countries, the prevalence of intense fear among primiparous women varied from 4.5% (in Belgium) to 15.6% (in Estonia). Among multiparous women, the prevalence of intense fear varied from 7.6% (in Iceland) to 15.2% (in Sweden). The results of the study conducted by Haines, Pallant, Karlström, & Hildingsson (2011) in Australia show that almost 30% of Australian and Swedish women had high levels of childbirth fear, with significantly higher levels in Swedish primiparous women, compared with multiparous women. In Portugal, there is limited research evidence on the fear of childbirth. One of the few studies addressing this subject was conducted in the North of Portugal. Using an explorative descriptive design, researchers found that approximately 57,2% of pregnant women (n=180) had fear of childbirth, 17.8% intense fear and 6.1% very intense fear (Loureiro, 2013).

The perceptions and experiences of pregnancy and birth are influenced by the emotional and psychological well-being of the woman. The fear of childbirth, as mentioned previously, has a profound impact on women. Thus, to minimize its effects, it is important to consider early interventions involving childbirth education classes where nurses can address and calm a woman’s fear in order to promote a more positive childbirth experience. This goal is only attainable if the childbirth levels of fear are identified and their main causes determined.

Therefore, was carry out a research with the following question: What are the levels of fear associated with childbirth by pregnant women and its causes?

An exploratory and descriptive study was conducted, with a convenience sample. Pregnant women in their second trimester of pregnancy were invited to participate. Inclusion criteria were women with 28 weeks’ gestation or more, aged 20 years or older and able to give informed consent. Data collection was carried out in an outpatient obstetric hospital in the northern region of Portugal, between July 2010 and July 2012. To evaluate the intensity of childbirth fear, a visual analogic scale of 10 points was used. This unidimensional instrument consists of a line with the right and left borders numbered from 0 to 10, where 0 corresponds to "no fear", 1 to 3 “slight fear”, 4 to 7 “moderate fear” and 8 to 10 means "intense fear". All pregnant women were asked to make a mark along the line representing the fear of childbirth currently being experienced. Interviews were also conducted to identify the causes of fear.

In order to understand if there was a relationship between the study variable and the sociodemographic variables, parametric and nonparametric statistics were used. For the analysis of qualitative data, the technique of Bardin content analysis was applied and for the analysis of quantitative data the Statistical Package for Social Sciences (SPSS), version 21 for Windows was used.

Ethics approval and informed consent were obtained.

The sample comprised 246 pregnant women, mostly Portuguese (n=237, 96.3%), aged between 20 and 41 years, mean 31.3 years (SD=4.4), and median and mode of 31 years. As for the level of education, 57.3% (n=141) of participants attended higher education, while 13.9% (n=34) completed basic education. Most of the women (72.0%, n=177) were married or cohabiting. Concerning labour, the majority of participants were primiparous women (77.2%, n=190).

Findings

Regarding the levels of fear of childbirth, the majority (98%; n=241) of the pregnant women had fear of childbirth: 60.2% (n=148) of participants reported moderate fear, 28% (n=69) intense fear, 20% (n=46) slight fear and 2% (n=5) indicated no fear. The average was 6.00 (SD=2,2), mode =5.0 and median = 6.0.

According to the socio-demographic variables no association was found between childbirth fear and age, education level and marital status.

In order to evaluate if the fear of childbirth was related to parity, the Mann-Whitney test was performed. In the sample of 219 nulliparous women the average rank was 127.22, and in the sample of 27 multiparous women it reached 93.31. The difference between the average values was very significant (U=2.141.50, p=.018), revealing that primiparous had more fear of childbirth than multiparous women.

An association was found between anxiety and the levels of fear of childbirth. Concerning the 202 women who reported being anxious, the average rank was 135.60, and 67.97 for the 44 women who did not mention being anxious. The difference between these average values was highly significant (U=6.887.50, p=.000), revealing that the pregnant women showing higher levels of anxiety were also the ones showing higher levels of childbirth fear.

Regarding the knowledge on labour and fear of childbirth, it was found that the 148 pregnant women who reported knowledge had an average rank of 114.42, and the 98 participants who considered having lack of knowledge had an average rank of 137.22. The difference between these values was very significant (U=8.596.50, p=.013), indicating that participants who referred not having knowledge on labour showed higher levels of fear of childbirth than those indicating knowledge.

The causes of fear associated with labour were described by participants, with a total of 95.5% (n=235) responses. After the analysis of participants’ statements, two main themes emerged: Causes of fear of childbirth related with the woman with two subcategories: Childbirth complications and Loss of control and Causes of fear of childbirth related with the fetus / newborn with two subcategories: Health and wellbeing (table 1).

Conclusions

These study findings provide a clear understanding about the fear of childbirth and its prevalence during pregnancy. This fear was found to be moderate by the majority of women and intense by approximately a third of the participants. These results were similar to the findings of Fenwick et al. (2009), concluding that 50% of women felt a moderate fear of childbirth, while 26% felt intense fear. Likewise, Loureiro’s (2013) results showed that 57.2% of pregnant women are fearful of childbirth, 17.8% feared it intensely, and 6.1% very intensely. However, these results raise some concerns, since, as previously stated, the fear of childbirth can determine the postponement of pregnancy, influence the decision on a caesarean section delivery, and impact daily life activities.

It was also found that anxiety is associated with childbirth fear. This is shared by several other authors, specifically (Saisto et al., 2001; Zar et al., 2001; Johnson & Slade, 2002; Alipour, Lamyian, Hajizadeh, & Vafaei, 2011), who refer to the importance of childbirth education, training relaxation techniques, visiting a delivery room, and developing a childbirth plan as effective interventions to mitigate fear and anxiety.

According to some researchers, parity was statistically associated with the fear of childbirth (Johnson, & Slade, 2002; Rouhe et al., 2009; Spice, Jones, Hadjistavropoulos, Kowalyk, & Stewart, 2009; Toohill, Fenwick, Gamble, & Creedy, 2014). Nulliparous women had a higher mean of childbirth fear compared to multiparous women. The development transition, the uncertainty of birth and the lack of knowledge are more likely to determine higher levels of fear in women having their first baby. Other researchers reached different outcomes. Nieminen et al. (2009), Haines et al., (2011) and Loureiro (2013), found no difference between parity groups, whereas Zar et al. (2001) reported childbirth fear levels slightly higher in multiparous women.

Some of the main causes of fear reported by participants included complications during childbirth and loss of control, and these results are in line with findings by other researchers (Lyberg, & Severinsson, 2010; Salomonsson, Wijma, & Alehagen, 2010; Pereira, Franco, & Baldin, 2011; Haines et al., 2011). The health condition and well-being of the fetus/newborn also contribute to childbirth fear as also supported by other authors (Klein, Sakala, Davis-Floyd, & Rooks, 2006; Lyberg, & Severinsson, 2010; Salomonsson, et al., 2010; Pereira et al., 2011; Haines et al., 2011). In modern societies, women have little experience with natural childbirth, do not always have positive maternal role models, successful birth stories, and lack adequate social support, and education regarding the birth process. Some of these factors help explain these findings.

Because of the impact that childbirth fear has on women and families, it is important to minimize its potentially negative effects. The identification of pregnant women at risk, their levels childbirth fear, and main causes will likely allow for an early intervention, promoting a better pregnancy experience and a more satisfying childbirth. According to several authors (Saisto et al., 2001; Waldenstrom et al., 2006; Nilsson & Lundgren, 2009; Fenwick et al., 2013), targeted interventions can include education regarding routine labour procedures, sharing experiences, and addressing feelings and beliefs. However, Portugal does not yet have a specific intervention plan targeted at pregnant women experiencing intense childbirth fear. Hence, this study highlights the importance of developing research that supports the planning and assessment of these types of programmes.

References

• Alipour, Z., Lamyian, M., Hajizadeh, E., & Vafaei, M. A. (2011). The association between antenatal anxiety and fear of childbirth in nulliparous women: a prospective study. Iranian Journal of Nursing and Midwifery Research, 16 (2), 169–173.

• Bahl, R., Strachan, B., & Murphy, D. J. (2004). Outcome of subsequent pregnancy three years after previous operative delivery in the second stage of labour: cohort study. British Medical Journal, 328, pp. 311–315. doi: DOI: 10.1136/ bmj.37942.546076.44

• Bardin, L. (2015). Análise de conteúdo. Lisboa: Edições 70, Lda.

• Fenwick, J., Gamble, J., Creedy, D. K., Buist, A., Turkstra, E., Sneddon, A., … Toohill, J. (2013). Study protocol for reducing childbirth fear: a midwife-led psycho-education intervention. BMC Pregnancy and Childbirth, 13, 190. Retirado de http://www.biomedcentral.com/content/pdf/1471-2393-13-190.pdf

• Fenwick, J., Gamble, J., Nathan, E., Bayes, S., & Hauck, Y. (2009). Pre-and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. Journal of Clinical Nursing, 18 (5), pp. 667–677. doi:

  Google Scholar

  Crossref

• Fenwick, J., Staff, L., Gamble, J., Creedy, D. K., & Bayes, S. (2010). Why do women request caesarean section in a normal, healthy first pregnancy? Midwifery, 26, 394-400.

• Haines, H., Pallant, J. F., Karlström, A., & Hildingsson, I. (2011). Cross-cultural comparison of levels of childbirth-related fear in an Australian and Swedish sample. Midwifery, 27 (4), 560-567. doi:

  Google Scholar

  Crossref

• Hildingsson, I. (2008). How much influence do women in Sweden have on caesarean section? A follow-up study of women’s preferences in early pregnancy. Midwifery, 24, 46-54. doi:

  Google Scholar

  Crossref

• Hildingsson, I., Rådestad, I., Rubertsson, C., & Waldenström, U. (2002). Few women wish to be delivered by caesarean section. BJOG, 109 (6), pp. 618-623. doi:

  Google Scholar

  Crossref

• Hofberg, K., & Ward, M.R. (2003). Fear of pregnancy and childbirth (review). Postgrad Med J, 79, pp. 505-510.

• International Council of Nurses (2011). CIPE® Versão 2 – Classificação Internacional para a Prática de Enfermagem. Lisboa: Ordem dos Enfermeiros.

• Johnson, R., & Slade, P. (2002). Does fear of childbirth during pregnancy predict emergency caesarean section? BJOG, 109 (11), pp. 1213-1221.

• Kjaergaard, H., Wijma, K., Dykes, A., & Alehagen, S. (2008). Fear of childbirth in obstetrically low-risk nulliparous women in Sweden & Denmark. J Reprod Infant Psyc, 26 (4), 340–350.

• Klein, M., Sakala, C., Davis-Floyd, R., & Rooks, J. (2006). Why do women go along with this stuff? Birth, 33, 245-250.

• Lang, A. J., Sorrell, J. T., Rodgers, C. S., & Lebeck, M. M. (2006). Anxiety sensitivity as a predictor of labor pain. European Journal of Pain, 10 (3), pp. 263–270. doi: 10.1016/j.ejpain.2005.05.001

• Larsen, K., O’Hara, M., Brewer, K., & Wenzel, A. (2001). A prospective study of self-efficacy expectancies and labour pain. Journal of Reproductive and Infant Psychology, 19 (3), pp. 203-214.

• Loureiro, S. A. (2013). O medo do parto. Contributo para a validação do W-DEQ para grávidas portuguesas. Tese de mestrado em Ciências de Enfermagem. Instituto de Ciências Biomédicas Abel Salazar – Universidade do Porto, Porto.

• Lyberg, A., & Severinsson, E. (2010). Fear of childbirth: mothers’ experiences of team-midwifery care – a follow-up study. Journal of Nursing Management, 18 (4), pp. 383-390. doi:

  Google Scholar

  Crossref

• Lukasse, M., Schei, B., & Ryding, A.L. (2014). Prevalence and associated factors of fear of childbirth in six European countries. Sexual Reprod Healthcare, 5 (3), 99 -106. doi:

  Google Scholar

  Crossref

• Melender, H-L. (2002). Fears and coping strategies associated with pregnancy and childbirth in Finland. J Midwifery Womens Health, 47, pp. 256-263.

• Nieminen, K., Stephansson, O., & Ryding. E. (2009). Women’s fear of childbirth and preferences for caesarean section - a cross sectional study at various stages of pregnancy in Sweden. Acta Obstet Gynecol Scand, 88, 807-813. doi:

  Google Scholar

  Crossref

• Nilsson, C. & Lundgren, I. (2009). Women´s lived experience of fear of childbirth. Midwifery, 25 (2), e1-e9.

• Nilsson, C., Lundgren, I., Karlström, A., & Hildingsson, I. (2012). Self-reported fear of childbirth and its association with women's birth experience and mode of delivery: a longitudinal population-based study. Women Birth, 25 (3),114-21. doi: 10.1016/j.wombi.2011.06.001.

• Pereira, R. R., Franco, S. C., & Baldin, N. (2011). A dor e o protagonismo da mulher na parturição. Rev Bras de Anestesiol, 61 (3), 376-388.

• Rouhe, H., Salmela-Aro, K., Halmesmäki, E., & Saisto, T. (2008). Fear of childbirth according to parity, gestational age, and obstetric history. BJOG, 116 (1), pp. 67-73. doi:

  Google Scholar

  Crossref

• Saisto, T., & Halmesmäki, E. (2003). Fear of childbirth: a neglected dilemma. Acta Obstet Gynecol Scand, 82, 201-208. doi:

  Google Scholar

  Crossref

• Saisto, T., Salmela-Aro, K., Nurmi, J. E., & Halmesmäki, E. (2001), Psychosocial predictors of disappointment with delivery and puerperal depression. A longitudinal study. Acta Obstet Gynecol Scand, 80, 39-45.

• Salomonsson, B., Wijma, K., & Alehagen, S. (2010). Swedish midwives’ perceptions of fear of childbirth. Midwifery, 26 (3), 327-337.

• Spice, K., Jones, S., Hadjistavropoulos, H., Kowalyk, K., & Stewart, S. (2009). Prenatal fear of childbirth and anxiety sensitivity. Journal of Psychosomatic Obstetrics & Gynecology, 30 (3), pp. 168-174

• Toohill, J., Fenwick, J., Gamble, J., & Creedy, D. K. (2014). Prevalence of childbirth fear in an Australian sample of pregnant women. BMC Pregnancy Childbirth, 14,14-275. doi:

  Google Scholar

  Crossref

• Waldenström, U., Hildingsson, I., & Ryding, E. L. (2006). Antenatal fear of childbirth and its association with subsequent caesarean section and experience of childbirth. BJOG, 113 (6), pp. 638-646. doi:

  Google Scholar

  Crossref

• Wax, J., Cartin, A., Pinette, M.G. & Blackstone, J. (2004). Patient choice cesarean: an evidence-based review. Obstet & Gynecol Surv, 59 (8), 601-616.

• Zar, M., Wijma, K., & Wijma, B. (2001). Pre-and postpartum fear of childbirth in nulliparous and parous women. Scand J Behav Therapy, 30, pp. 75-84.