This article was first published by The British Journal of Midwifery, April 2011, Vol 19, No 4
British Journal of Midwifery (BJM) is a clinical journal for midwives. Published each month, the journal is written by midwives for midwives and peer reviewed by some of the foremost authorities in the profession - www.britishjournalofmidwifery.com
This article is based on a review of the literature related to fear of childbirth, and pragmatically considers issues for midwifery practice. Research shows that around one in ten women in the developed world is affected by severe and disabling fear of childbirth during pregnancy (Saisto and Halmesmaki, 2003). An important finding in the research is the significant link between fear of childbirth and caesarean section (for which the UK currently has very high rates). Fear is also associated with a negative birth experience. While personality and social factors are shown to raise the risk of severe fear of childbirth, midwives need to recognize that loss of control, misinformation and previous traumatic experiences have a serious detrimental effect on women’s perceived capacity to give birth vaginally.
Pregnancy and childbirth are normal physiological events that are associated with great emotional, psychological and cultural significance for women and their families. For many women a degree of fear around childbirth is a normal and potentially useful reaction to an inherently unpredictable process. However, while birth can be frightening and challenging, it can also be one of the most fulfilling and powerful experiences in a woman’s life. In Western countries, perinatal morbidity and mortality of mother and baby have become very rare and for most healthy women birth should be a positive life event associated with minimal risk of an adverse outcome. It therefore appears paradoxical that many women’s experience of childbirth is significantly impaired by fear, and their anxieties translate into low expectations of being able to cope in labour (Eriksson et al, 2006).
Much of the research around fear of childbirth has taken place in Scandinavian countries, where recognition and treatment of childbirth fear is long-established. There exists considerable scope in the UK to advance the limited understanding of the causes, impact and treatment of childbirth fear. While 80% of women describe common childbirth anxieties (Saisto and Halmesmäki, 2003), intense fear is expressed by over 20% (Hofberg and Ward, 2004), with 6–10% reporting pathological levels of fear (Saisto and Halmesmäki, 2003). Maternity caregivers are identified as both a cause of this fear and a pivotal mediating factor in reducing it, demonstrating the importance to midwifery practice of understanding, recognizing and addressing fear.
The Causes Of Fear Of Childbirth
Broadly analysed, the causes of fear of childbirth can be seen as:
It is also interesting that, as women’s empowerment in the West has grown (Reiger and Dempsey, 2006), so the cultural and personal confidence in their capacity to give birth appears to have declined, accompanied by increased and often debilitating levels of childbirth fear.
A number of causes of fear of childbirth emerge from the research, including negative stories and fear of pain in labour which is associated with suffering, shame, loss of control and helplessness (Fenwick et al, 2009). Sjögren (2000) found that the most common reasons for childbirth fear were a lack of trust in obstetric staff and feeling excluded from decisions. This emphasizes the importance of good midwifery care, which has the potential to improve women’s experiences of pregnancy and childbirth by offering information, choice, agency and advocacy.
Studies of personality variables suggest that depression, anxiety and low self-esteem are significantly related to a pregnant woman’s tendency to fear childbirth (Waldenström et al, 2006; Laursen et al, 2008; Hall et al, 2009). Lowe (2000) found that fearful women have lower self-efficacy, implying that they have little confidence in their ability to labour effectively, and this is an area where a good midwife with a strong faith in women’s bodies can provide invaluable support. Saisto and Halmesmäki (2003) recommended that midwives be alert to women presenting with antenatal complaints such as recurrent abdominal pain, as this may be masking anxieties about the birth.
In terms of social issues, research demonstrates that women who are young, have a low educational level and a poor social network, or who express dissatisfaction with their partners (Waldenström et al, 2006; Ryding et al, 2007; Laursen et al, 2008) are more likely to be affected by childbirth fear. Knowing that these vulnerable women are at risk of experiencing debilitating levels of fear could help midwives discern which women need particular help to build their self-esteem or to improve their social networks, and which women may need to be referred for psychological therapy.
‘Horror stories’ about birth have been identified as an important cause of fear, particularly for primiparous women (Ryding et al, 2007) and these contribute to the reframing of the birth experience as frightening (Fenwick et al, 2009). While alarming information is predominantly disseminated by friends, family and the media (Serçekuș and Okumuș, 2007), stories told by health professionals also have a strong explanatory power for causing fear (Melender, 2002). It may be that our sociocultural climate undermines women’s belief in themselves and their bodies (Lowe, 2000) and that their authoritative knowledge has been eroded (Fisher et al, 2006). In turn, escalating intervention and operative rates are seen by women as proof that birth is dangerous and frightening and needs to be managed medically. As the guardians of normal birth, there is much midwives can and should do to redress the balance, restore women’s trust in their bodies and ensure that everyone has access to the support, care and information that promote a positive birth experience.
Prior Experiences And Control
Fear resulting from a sense of powerlessness is a recurrent theme in much of the research, with Cheung et al (2006) finding a significant negative relationship between maternal anxiety and feelings of control, and the most common fear in Lowe’s study (2000) was fear of losing control during the delivery. Studies have demonstrated that if a woman feels able to control factors around her birth, then anxiety may be lessened (Green et al, 2003), and this is recognized in Department of Health (DH) policy (1993; 2007). In Ryding et al’s (2007) study, 61% of women expressing fear worried about not being able to influence decisions, compared to only 18% in the comparison group. Geissbuehler and Eberhard (2002) found that women were afraid of losing control and being unable to ‘behave appropriately’ during labour. Similarly, Fisher et al’s qualitative exploration (2006) revealed the depth of women’s fears of losing control both physically and emotionally. By providing enhanced communication, appreciating the importance of informed consent, and focusing on respecting and responding to women’s individual needs, midwives should be able to work with women to diminish their fears.
The Effects Of Childbirth Fear
Research has shown that fear affects women in a number of ways, including:
In Western societies, research findings have associated fear with an increase in birth intervention and elective and emergency caesarean section (Laursen et al, 2009) at a time when the rise in caesarean section rates is a serious concern throughout the developed world. Fear has also been shown to increase risks of postnatal depression, post-traumatic stress disorder and impaired mother-infant bonding (Fisher et al, 2006), clearly highlighting the importance of nurturing women’s psychological health throughout pregnancy.
As well as personal and societal effects, fear of childbirth in the UK increases NHS costs due to maternal requests for caesarean section. The National Institute for Health and Clinical Excellence (NICE) (2004) does not recognize fear of childbirth as a justification for caesarean section, but acknowledges that obstetricians in the UK carry out caesarean sections for around half the women who have requested them because of their fears. The caesarean section rate in England is 25% (NHS Information Centre, 2009), considerably higher than the maximum medically justified rate of 15% as defined by the World Health Organization (WHO) (1985). While there are many reasons for the worldwide rise in caesarean sections, a significant and potentially modifiable factor is maternal request — one Finnish hospital calculated that 8% of all caesarean sections were carried out because of fear of vaginal delivery (Saisto et al, 2001).
Adrenaline is associated with a decrease in uterine activity, while cortisol is linked to pain experienced in labour (Alehagen et al, 2005). An understanding of the hormonal stress response activated by fear suggests that a frightened labouring woman may be at higher risk of a protracted labour, fetal distress and emergency caesarean section. Laursen et al (2009) found that fear of childbirth was associated with a diagnosis of dystocia but not with fetal distress. Findings relating to emergency caesarean section have varied, with Laursen et al (2009) and Fenwick et al (2009) confirming the earlier results of Ryding et al (1998) which showed that fear of childbirth increases the risk of childbirth significantly. However, Waldenström et al (2006) and Johnson and Slade (2002) found no statistical differences to demonstrate an association between fear and emergency caesarean section.
In terms of women’s satisfaction, Ryding et al (2007) found that women with intense fear had a poorer quality experience, and the group of women in Waldenström et al (2006)’s study who were fearful but did not undergo counselling had a strong association with a negative assessment of labour and delivery. Fear of childbirth was shown to have an impact on feelings of stress and anxiety and on everyday activities (Melender, 2002) as well as on fatigue and sleep deprivation (Hall et al, 2009), with fears engendering a sense of loneliness and inferiority (Nilsson and Lundgren, 2007).
The findings in the study by Melender (2002) highlighted pregnant women’s performance anxieties — ‘fear of being an incompetent parturient’ — as a factor influencing childbirth fear. This will resonate with many midwives who will be familiar with hearing that women do not feel capable. Gaskin (2003) recommended that women actively surrender to birth, urging them to ‘let your monkey do it’, and good midwifery information and encouragement can support women in this challenge. In a study by Nilsson and Lundgren (2007), women fearful of childbirth identified themselves as an ‘inferior mother-to-be’, communicating a strong sense of personal failure as a woman. The women interviewed discussed the appeal of a ‘normal’ birth, revealing that their preference was to be helped to overcome their fears rather than to be granted the caesarean section they had requested. These findings are confirmed in a study by Nerum et al (2006) of the effects of counselling on maternal requests for caesarean section.
Treating Fear Of Childbirth
Given its prevalence and its impact, fear of childbirth can be seen as a public health issue that needs addressing. An understanding of the literature can enable midwives to gain a better insight into fears surrounding childbirth, in order to improve midwifery approaches to identifying which women may be fearful, and managing and appeasing their fears.
Turning Fear To Trust
Tritten (2003) argued that fear is the force behind most of the bad decisions a woman makes, calling on midwives to turn fear to trust in order to facilitate an understanding of the satisfaction birth can bring. Many women will use fear of pain as a more socially acceptable explanation for complex and personal feelings of fear or inadequacy around birth (Odent, 1994), and Alehagen et al (2005) suggested that epidural analgesia is not a sufficient response to fear as it masks more difficult issues that should be identified and addressed by trusted caregivers antenatally.
A study by Fisher et al (2006) conveyed the desperation and impotence that some women feel, and the midwife’s unique position to address and allay their fears. While many midwives are aware that fear has a detrimental effect on the women in their care, no established guidance for identification exists in the UK and, in the absence of a care or referral pathway, midwives remain unsure of how best to support fearful women. As a discussion of a woman’s fears is not built into routine midwifery care in the UK, many midwives have little exposure to their content or manifestations, so international research provides useful insight from midwifery practices in other countries.
The stigma associated with psychological problems means that women may be unwilling to disclose their fears, making it all the more important that the midwife should build a trusting relationship where feelings and anxieties can be discussed openly. It is a concern, however, that poor treatment by maternity staff emerges from research as both a cause and a consequence of women’s fears surrounding birth (Melender, 2002; Fisher et al, 2006; Nilsson and Lundgren, 2007; Fenwick et al, 2009). While women who feel supported by caregivers benefit through enhanced psychological wellbeing that endures into parenthood (Laursen et al, 2009), a lack of trust in maternity staff was reported by some women (Fenwick et al, 2009), and a fear that midwives would be unfriendly (Eriksson et al, 2006) and interfering (Melender, 2002). Nilsson and Lundgren (2007) found that midwives were unsympathetic and evasive in their attitude when women expressed fear of childbirth, and they urged caregivers to remember the power midwives have and to use it to the best advantage of the woman in their care. Odent (1994) stressed that the importance of midwives cannot be exaggerated, and advised that they consider the environment in which they care for women, their verbal and non-verbal communication and the conditioning power of the language they use.
The Swedish ‘Aurora’ clinics to treat fear of childbirth involve a team of experienced midwives supported by an obstetrician, psychologist, social worker and often a psychiatrist (Waldenström et al, 2006). Similar treatment is available in Finland, Denmark and Norway and it includes counselling, relaxation techniques and a visit to the delivery ward. The Finnish authors Saisto and Halmesmäki (2003) advocated the use of cognitive behavioural therapy (CBT), which teaches constructive thinking to reduce perceptions of stress. Advantages of CBT are that it is brief, of changeable duration and can focus on one problem. Other authors question whether CBT is sufficient to treat a complex condition which is integrated in a personality pattern of greater vulnerability (Ryding et al, 2007), suggesting a ‘quick fix’ approach is inadequate (Bergström et al, 2009).
Geissbuehler and Eberhard (2002) described the Swiss treatment system of ‘trust-building contact’ which focuses on maximizing continuity of care and offering a broad spectrum of pain medication. Without specifying what form it should take, NICE (2004) recommends counselling for women requesting a caesarean section because of fear of childbirth. Very few specialist services exist in the UK; however, the Hope Clinic in Birmingham is able to offer fearful women psychological assessment, counselling, and planning and support for pregnancy, labour and birth (Gutteridge, 2010), and the Birth Trauma Association gives emotional and practical support to multiparous women fearing their next delivery.
Swedish women reported high levels of satisfaction with the counselling provided to treat fear of childbirth (Ryding et al, 2003), yet even after the intervention, these women had a more frightening experience in their subsequent delivery than those in the comparison group, suggesting that counselling in late pregnancy does not fully alleviate fear of childbirth. This raises the question of how successful the existing treatment is, and further quantitative research is needed to evaluate CBT, group psychotherapy with relaxation and other interventions already in use. Randomized controlled trials to establish effective treatment for fear of childbirth may inform future care pathways to support women in the UK whose fears are affecting their pregnancy.
As UK midwives may be unused to discussing women’s fears, a mandatory routine question at the booking interview related to thoughts and emotions about birth, repeated at intervals antenatally, would provide a helpful structure for ensuring the subject is raised, midwives listen, and women have the opportunity to discuss their concerns. A suggested open question would be ‘How do you feel about your labour and birth?’
The establishment of clear national and local guidelines on counselling for fearful women and better access to psychological services would assist midwives in offering the best support to women in their area. As the research suggests women are vulnerable to the influences of inaccurate data and frightening stories about birth, evidence-based information presented with sensitivity by health professionals is paramount. Careful attention should be paid to issues of informed consent in order to increase women’s personal sense of control over their birth and their trust in midwives. Good midwifery care that offers support and reassurance, improves self-esteem, engenders trust, and where midwives take the time to listen to women can play a crucial role in reducing, identifying and treating women’s fears.
Childbirth fear is a highly sensitive issue for many women and is associated with considerable stigma. In the absence of any current established treatment, it is essential that midwives in the UK work to build a safe and trusting relationship with the women in their care. Special attention should be paid to women at greater risk of fear of childbirth because of social or personality factors or previous traumatic experiences, and multiparous women in need of debriefing should be identified and referred to appropriate services.
Philosophical and behavioural changes may be necessary for some midwives, with closer attention being paid to a woman’s satisfaction with her birth experience in order to offer optimal psychological support during the perinatal period. By reflecting on respect and how information is conveyed, midwives are in a privileged position to support women in regaining cultural knowledge and ownership of childbirth.
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