OJOG  Vol.4 No.9 , June 2014
Psycho-Social Predictors of Childbirth Fear in Pregnant Women: An Australian Study

Background: Around 20% of birthing women report high levels of childbirth fear. Fear potentially impacts women’s emotional health, preparation for birth, and birth outcomes. Evidence suggests that personal and external factors contribute to childbirth fear, however results vary. Aim: To identify pyscho-social factors associated with childbirth fear and possible antenatal predictors of childbirth fear according to women’s parity. Method: 1410 women in second trimester and attending one of three public hospitals in south-east Queensland were screened for childbirth fear using the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ). Other measures included the Edinburgh Depression Scale (EPDS), Decisional Conflict Scale (DCS) and items from the EuroQol (EQ-5D) targeting Anxiety/Depression and Pain/Discomfort. In addition items measuring a previous mental health condition, social support and knowledge were used. Preferred mode of birth was also collected. Psycho-social factors were analysed to determine associations with childbirth fear. Multivariate analysis was used to determine predictors of fear. Results: Thirty-one percent (n = 190/604) of nulliparous and 18% (n = 143/782) of multiparous women reported high fear levels. Having a mental health history, desiring a caesarean section, reporting moderate to high pain during pregnancy, having a non-supportive partner and perceiving less childbirth knowledge than peers, were associated with childbirth fear. Standard multiple regression analyses by parity determined that depression, decisional conflict, low social support and less perceived knowledge predicted levels of childbirth fear. The model explained 32.4% of variance in childbirth fear for nulliparous and 29.4% for multiparous women. Conclusion: Psychosocial factors are significantly associated with childbirth fear. The identification of predictive psychosocial factors for childbirth fear indicates the importance of observing, assessing, and developing support strategies for women. Such strategies are required to decrease anxiety and depression for women during pregnancy, promote normal birth, and build social support to improve women’s feelings and positive expectations of birth.

Cite this paper
Toohill, J. , Fenwick, J. , Gamble, J. , Creedy, D. , Buist, A. and Ryding, E. (2014) Psycho-Social Predictors of Childbirth Fear in Pregnant Women: An Australian Study. Open Journal of Obstetrics and Gynecology, 4, 531-543. doi: 10.4236/ojog.2014.49075.
[1]   Adams, S., Eberhard-Gran, M. and Eskild, A. (2012) Fear of Childbirth and Duration of Labour: A Study of 2206 Women with Intended Vaginal Delivery. BJOG, 119, 1238-1246.

[2]   Fenwick, J., Gamble, J., Nathan, E., Bayes, S. and 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, 667-677. http://dx.doi.org/10.1111/j.1365-2702.2008.02568.x

[3]   Ryding, E., Lukasse, M. and Schei, B. (2012) Fear of Childbirth—Does It Affect Mode of Delivery. The BIDENS Study—Results from Six Countries. Acta Obstetricia et Gynecologica Scandinavica, 91, 38.

[4]   Ryding, E., Wijma, B., Wijma, K. and Rydhstrom, H. (1998) Fear of Childbirth during Pregnancy May Increase the Risk of Emergency Cesarean Section. Acta Obstetricia et Gynecologica Scandinavica, 77, 542-547. http://dx.doi.org/10.1080/j.1600-0412.1998.770512.x

[5]   Sydsjo, G., Sydsjo, A., Gunnervik, C., Bladh, M. and Josefsson, A. (2012) Obstetric Outcome for Women Who Received Individualized Treatment for Fear of Childbirth during Pregnancy. Acta Obstetricia et Gynecologica Scandinavica, 91, 44-49.

[6]   Nerum, H., Halvorsen, L., Sorlie, T. and Oian, P. (2006) Maternal Request for Cesarean Section Due to Fear of Birth: Can It Be Changed through Crisis-Oriented Counseling? Birth, 33, 221-228.

[7]   Nieminen, K., Stephansson, O. and Ryding, E.L. (2009) Women’s Fear of Childbirth and Preference for Cesarean Section—A Cross-Sectional Study at Various Stages of Pregnancy in Sweden. Acta Obstetricia et Gynecologica Scandinavica, 88, 807-813.

[8]   Sjogren, B. (1998) Fear of Childbirth and Psychosomatic Support. Acta Obstetricia et Gynecologica Scandinavica, 77, 819-825. http://dx.doi.org/10.1080/j.1600-0412.1998.770807.x

[9]   Waldenstrom, U., Hildingsson, I. and Ryding, E. (2006) Antenatal Fear of Childbirth and Its Association with Subsequent Caesarean Section and Experience of Childbirth. BJOG, 113, 638-646.

[10]   Wiklund, I., Edman, G., Ryding, E. and Andolfa, E. (2008) Expectation and Experiences of Childbirth in Primiparae with Caesarean Section. BJOG, 115, 324-331.

[11]   Wax, J., Cartin, A., Pinette, M. and Blackstone, J. (2004) Patient Choice Cesarean: An Evidence-Based Review. Obstetrical & Gynecological Survey, 59, 601-616.

[12]   Saisto, T., Toivanen, R., Salmela-Aro, K. and Halmesmaki, E. (2006) Therapeutic Group Psychoeducation and Relaxation in Treating Fear of Childbirth. Acta Obstetricia et Gynecologica Scandinavica, 85, 1315-1319. http://dx.doi.org/10.1080/00016340600756920

[13]   Rouhe, H., Salmela-Aro, K., Gissler, M., Halmesmaki, E. and Saisto, T. (2011) Mental Health Problems Common in Women with Fear of Childbirth. BJOG, 118, 1104-1111. http://dx.doi.org/10.1111/j.1471-0528.2011.02967.x

[14]   Laursen, M., Hedegaard, M. and Johansen, C. (2008) Fear of Childbirth: Predictors and Temporal Changes among Nulliparous Women in the Danish National Birth Cohort. BJOG, 115, 354-360.

[15]   Storksen, H., Eberhrd-Gran, M., Garthus-Niegel, S. and Eskild, A. (2012) Fear of Childbirth; The Relation to Anxiety and Depression. Acta Obstetricia et Gynecologica Scandinavica, 91, 237-242.

[16]   S?derquist, J., Wijma, B., Thorbert, G. and Wijma, K. (2009) Risk Factors in Pregnancy for Post-Traumatic Stress and Depression after Childbirth. BJOG: An International Journal of Obstetrics & Gynaecology, 116, 672-680. http://dx.doi.org/10.1111/j.1471-0528.2008.02083.x

[17]   Raisanen, S., Lehto, S., Nielsen, H., Gissler, M., Kramer, M., et al. (2013) Fear of Childbirth Predicts Postpartum Depression: A Population-Based Analysis of 511 422 Singleton Births in Finland. BMJ Open, 3, e004047. http://dx.doi.org/10.1136/bmjopen-2013-004047

[18]   Toohill, J., Fenwick, J., Gamble, J. and Creedy, D.K. (2014) Prevalence of Childbirth Fear in an Australian Sample of Pregnant Women (in Press).

[19]   Hall, W., Hauck, Y., Carty, E., Hutton, E., Fenwick, J., et al. (2009) Childbirth Fear, Anxiety, Fatigue, and Sleep Deprivation in Pregnant Women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 38, 567-576. http://dx.doi.org/10.1111/j.1552-6909.2009.01054.x

[20]   Rouhe, H., Salmela-Aro, K., Halmesm?ki, E. and Saisto, T. (2009) Fear of Childbirth According to Parity, Gestational Age, and Obstetric History. BJOG: An International Journal of Obstetrics & Gynaecology, 116, 67-73. http://dx.doi.org/10.1111/j.1471-0528.2008.02002.x

[21]   Zar, M., Wijma, K. and Wijma, B. (2001) Pre-and Postpartum Fear of Childbirth in Nulliparous and Parous Women. Scandinavian Journal of Behaviour Therapy, 30, 75-84.

[22]   Ryding, E., Persson, A., Onell, C. and Kvist, L. (2003) An Evaluation of Midwives’ Counseling of Pregnant Women in Fear of Childbirth. Acta Obstetricia et Gynecologica Scandinavica, 82, 10-17.

[23]   Fenwick, J., Gamble, J., Creedy, D., Buist, A., Turkstra, E., et al. (2013) Study Protocol for Reducing Childbirth Fear: A Midwife-Led Psycho-Education Intervention. BMC Pregnancy and Childbirth, 13, Published Online.

[24]   Cox, J., Holden, J. and Sagousky, R. (1987) Detection of Postnatal Depression Development of the 10 Item Edinburgh Depression Scale. BMJ, 150, 782-786.

[25]   O’Connor, A. (2010) User Manual—Decisional Conflict Scale (16 Item Statement Format) [Document on the Internet]. Ottawa Hospital Research Institute, Ottawa.

[26]   Brooks, R. (1996) EuroQol: The Current State of Play. Health Policy, 37, 53-72.

[27]   The EuroQol Group (1990) EuroQol: A New Facility for the Measurement of Health-Related Quality of Life. Health Policy, 16, 199-208. http://dx.doi.org/10.1016/0168-8510(90)90421-9

[28]   Drummond, J. and Rickwood, D. (1997) Childbirth Confidence: Validating the Childbirth Self-Efficacy Inventory (CBSEI) in an Australian Sample. Journal of Advanced Nursing, 26, 613-622.

[29]   EuroQuol Group (2009) EQ5D User Guide. Version 2. http://www.euroquol.org

[30]   Cohen, J. (1988) Statistical Power Analysis for the Behavioural Sciences. 2nd Edition, Erlbaum Associates, Hillsdale.

[31]   Saisto, T., Salmela-Aro, K., Nurmi, J. and Halmesm?ki, E. (2001) Psychosocial Characteristics of Women and Their Partners Fearing Vaginal Childbirth. BJOG: An International Journal of Obstetrics & Gynaecology, 108, 492-498. http://dx.doi.org/10.1111/j.1471-0528.2001.00122.x

[32]   Zar, M., Wijma, K. and Wijma, B. (2002) Relations between Anxiety Disorders and Fear of Childbirth during Late Pregnancy. Clinical Psychology & Psychotherapy, 9, 122-130.

[33]   Atwood, A. (2013) Antenatal Anxiety: Origins, Effects, and Interventions. International Journal of Childbirth Education, 28, 54-60.

[34]   Brockington, I., Macdonald, E. and Wainscott, G. (2006) Anxiety, Obsessions and Morbid Preoccupations in Pregnancy. Archives of Women’s Mental Health, 9, 253-263.

[35]   Lee, A., Lam, S., Lau, S.M., Chong, C., Chui, H., et al. (2007) Prevalence, Course, and Risk Factors for Antenatal Anxiety and Depression. Obstetrics & Gynecology, 110, 1102-1112.

[36]   Rofé, Y., Littner, M. and Lewin, I. (1993) Emotional Experiences during the Three Trimesters of Pregnancy. Journal of Clinical Psychology, 49, 3-12.

[37]   Shinkawa, H., Shimada, M., Hirokane, K., Hayase, M. and Inui, T. (2012) Development of a Scale for Pregnancy-Related Discomforts. Journal of Obstetrics and Gynaecology Research, 38, 316-323. http://dx.doi.org/10.1111/j.1447-0756.2011.01676.x

[38]   Saisto, T., Kaaja, R., Ylikorkala, O. and Halmesmaki, E. (2001) Reduced Pain Tolerance during and after Pregnancy in Women Suffering from Fear of Labor. Pain, 93, 123-127.

[39]   Nordeng, H., Hansen, C., Garthus-Niegel, S. and Eberhard-Gran, M. (2012) Fear of Childbirth, Mental Health, and Medication Use during Pregnancy. Archives of Women’s Mental Health, 15, 203-209.

[40]   Ryding, E., Wirfelt, E., Wangborg, I., Sjogren, B., Edman, G., et al. (2007) Personality and Fear of Childbirth. Acta Obstetricia et Gynecologica Scandinavica, 68, 814-820.

[41]   Haines, H., Pallant, J., Karlstram, A. and Hildingsson, I. (2011) Cross-Cultural Comparison of Levels of ChildbirthRelated Fear in an Australian and Swedish Sample. Midwifery, 27, 560-567.

[42]   Turner, R.J., Grindstaff, C. and Phillips, N. (1990) Social Support and Outcome in Teenage Pregnancy. Journal of Health and Social Behavior, 31, 43-57. http://dx.doi.org/10.2307/2137044

[43]   Collins, N., Dunkel-Schetter, C., Lobel, M. and Scrimshaw, S. (1993) Social Support in Pregnancy: Psychosocial Correlates of Birth Outcomes and Postpartum Depression. Journal of Personality and Social Psychology, 65, 1243-1258. http://dx.doi.org/10.1037/0022-3514.65.6.1243

[44]   Rising, S. (1998) Centering Pregnancy: An Interdisciplinary Model of Empowerment. Journal of Nurse-Midwifery, 43, 46-54. http://dx.doi.org/10.1016/S0091-2182(97)00117-1

[45]   Haines, H., Rubertsson, C., Pallant, J. and Hildingsson, I. (2012) Womens’ Attitudes and Beliefs of Childbirth and Association with Birth Preference: A Comparison of a Swedish and an Australian Sample in Mid-Pregnancy. Midwifery, 28, e850-e856. http://dx.doi.org/10.1016/j.midw.2011.09.011

[46]   Lowe, N. (1993) Maternal Confidence for Labor: Development of the Childbirth Self-Efficacy Inventory. Research in Nursing & Health, 16, 141-149. http://dx.doi.org/10.1002/nur.4770160209

[47]   Helk, A., Spilling, H. and Smeby, N. (2008) Psychosocial Support by Midwives of Women with a Fear of Childbirth: A Study of 80 Women. Nordic Journal of Nursing Research & Clinical Studies, 28, 47-49.

[48]   Lothian, J.A. (2008) Choice, Autonomy, and Childbirth Education. The Journal of Perinatal Education, 17, 35-38. http://dx.doi.org/10.1624/105812408X266278

[49]   McCourt, C. and Stevens, T. (2009) Relationship and Reciprocity in Caseload Midwifery. In: Hunter, B. and Deery, R., Eds., Emotions in Midwifery and Reproduction, Palgrave Macmillan, New York.

[50]   Menke, J., Fenwick, J., Gamble, J., Brittain, H. and Creedy, D. (2014) Midwifery Group Practice for Socially Disadvantaged and Vulnerable Women: Midwives Perceptions of Organizational Structures and Processes Influencing Care. Midwifery. http://dx.doi.org/10.1016/j.midw.2013.12.015

[51]   Wijma, K., Wijma, B. and Zar, M. (1998) Psychometric Aspects of the W-DEQ; A New Questionnaire for the Measurement of Fear of Childbirth. Journal of Psychosomatic Obstetrics & Gynecology, 19, 84-97. http://dx.doi.org/10.3109/01674829809048501

[52]   Murray, D. and Cox, J. (1990) Screening for Depression during Pregnancy with the Edinburgh Depression Scale (EPDS). Special Issue: Psychiatric Disorders Associated with Childbearing. Journal of Reproductive and Infant Psychology, 8, 99-107. http://dx.doi.org/10.1080/02646839008403615

[53]   Beyondblue (2011) Clinical Practice Guidelines for Depression and Related Disorders—Anxiety, Bipolar Disorder and Puerperal Psychosis—In the Perinatal Period. A Guideline for Primary Care Health Professionals. The National Depression Initiative, Melbourne.

[54]   Williams, A. (2005) The EuroQol Instrument. In: Kind, P., Brooks, R. and Rabin, R., Eds., EQ-5D Concepts and Methods: A Developmental History, Springer, Dordrecht, 1-17.