Download Women`s fear of childbirth and preference for cesarean section

Acta Obstetricia et Gynecologica. 2009; 88: 807813
ORIGINAL ARTICLE
Women’s fear of childbirth and preference for cesarean section
cross-sectional study at various stages of pregnancy in Sweden
a
KATRI NIEMINEN1, OLOF STEPHANSSON2,3 & ELSA LENA RYDING3
1
Department of Obstetrics and Gynaecology, Motala Hospital, Motala, Sweden, 2Department of Medicine, Clinical
Epidemiology Unit, Karolinska Institutet/Karolinska University Hospital, Stockholm, Sweden, and 3Department of Woman
and Child Health, Division of Obstetrics and Gynaecology, Karolinska Institutet/Karolinska University Hospital, Stockholm,
Sweden
Abstract
Objective. To investigate Swedish women’s level of antenatal fear of childbirth at various gestational ages, and factors
associated with intense fear and with preference for cesarean section. Design. A cross-sectional study. Setting. All antenatal
clinics in four geographical areas. Sample. Thousand six hundred and thirty-five pregnant women at various gestational ages
recruited during SeptemberOctober 2006. Method. A questionnaire completed at the antenatal clinic. The women reported
their appraisal of the approaching delivery according to the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ). Main outcome measures. The level of fear of childbirth and preferred mode of delivery. Results. Mean W-DEQ score
was 62.8. The prevalence of intense fear of childbirth (W-DEQ score ]85) was 15.8% and very intense fear (tocophobia)
(W-DEQ score ]100) 5.7%. Nulliparous women had a higher mean score than parous women, but more parous women
reported an intense fear. Preference for cesarean section was associated with fear of childbirth (OR 11.79, 6.122.59 for
nulliparous and OR 8.32, 4.3615.85 for parous women) and for parous women also with a previous cesarean section (OR
18.54, 9.5535.97), or an instrumental vaginal delivery (OR 2.34, 1.025.34). The level of fear of childbirth was not
associated with the gestational age. Conclusions. When a woman requests a cesarean section, both primary fear of birth and
traumatic childbirth experiences need to be considered and dealt with. The W-DEQ can be used at any time during
pregnancy in order to identify pregnant women who suffer from intense fear of childbirth.
Key words: Fear of childbirth, tocophobia, cesarean section, W-DEQ
Introduction
Fear of childbirth in pregnant women has been
associated with a previous negative birth experience
(1), an increased risk of operative interventions
during the delivery (2), and with depression as well
as anxiety syndromes (3). There are also indications
that maternal stress, anxiety, and/or depression
could have adverse effects on the fetus and young
infant (4). Intense fear of childbirth can be defined
as fear before, during, or after the delivery. The
woman is afraid of getting pregnant or giving birth or
the fear disturbs her normal life and activities (5).
Women with intense fear of childbirth may benefit
from treatment (68).
It is commonly believed that pregnant women’s
fear of childbirth has increased in Sweden. A larger
proportion of pregnant women request a cesarean
section today compared with a few years ago (9).
There is evidence that fear of childbirth is an
important factor when women ask for a cesarean
(10). Fear of childbirth has been measured and
reported in various ways (2,7,11), which makes it
difficult to estimate any change in the level of this
form of anxiety in the population. There are
standardized measurement tools, such as the Wijma
Delivery Expectancy/Experience Questionnaire
(W-DEQ) (5). This method was used in population-based studies in the early 1990s of women in
their third trimester of pregnancy (2,12). It was
demonstrated that fear of childbirth was a separate,
specific domain of anxiety, although associated with
anxiety in general (13).
Correspondence: Katri Nieminen, Department of Obstetrics and Gynaecology, Motala Hospital, SE-591 85 Motala, Sweden. E-mail: [email protected]
(Received 26 November 2008; accepted 27 April 2009)
ISSN 0001-6349 print/ISSN 1600-0412 online # 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.1080/00016340902998436
808
K. Nieminen et al.
The aims of this study were to investigate the
prevalence of intense fear of childbirth in 2006 in
Sweden, the association between the level of fear of
childbirth and gestational age, the risk factors for
intense fear of childbirth in primi and multiparous
women, and risk factors associated with the preference for cesarean section in primi and multiparous women.
Material and methods
This is a cross-sectional study of pregnant women
in Sweden. All Swedish-speaking pregnant women
who visited the antenatal clinic at some time in
their pregnancy during a period of eight weeks
(SeptemberOctober 2006) in the districts of northwest Stockholm, Helsingborg, Norrköping, and Motala, were invited to participate anonymously in the
study. These cities represent part of the capital
(Stockholm), two middle-sized cities with surrounding countryside (Helsingborg and Norrköping) and
one small town with surroundings (Motala). In all,
1,635 women were enrolled and 29 women declined
(participation rate 98.3%). The women filled in a
questionnaire at the antenatal clinic, after giving their
informed consent to their midwife.
The questionnaire included The Wijma Delivery
Expectancy/Experience Questionnaire (W-DEQ)
form A, as well as demographic and obstetric data.
The W-DEQ (version A) measures fear of childbirth as operationalized by the cognitive appraisal of
the approaching delivery. The 33-item graphic selfassessment rating scale has six scale steps per item,
ranging from ‘not at all’ to ‘extremely’ with a
minimum score of 0 and a maximum of 165. The
higher the score, the greater the fear of childbirth
manifested. According to existing norm values, a
score ]85 indicates an intense fear of childbirth,
influencing the woman’s well-being, and a score
]100 indicates a very intense, phobic fear (11). The
questionnaire included information on maternal age,
gestational week, educational level, whether the
woman was living with a partner, reproductive
history including parity and previous instrumental
delivery, or cesarean section and preferable mode of
delivery for the present pregnancy. Maternal age was
categorized as less than 25 years, 2529 years, 3034
years, or 35 years or older. Maternal education level
categories used were 11 years or less, alternatively 12
years or more.
Statistical analysis was performed by means of
unpaired t-test or ANOVA for continuous variables,
a chi-squared test for categorical variables, and linear
regression analysis for correlation between gestational week and W-DEQ score. A p-value B5% was
considered significant. We used unconditional logistic-regression analysis to model the risk of a W-DEQ
score of ]85 and preference for cesarean section as
a function of maternal characteristics and previous
reproductive history. Primiparous and parous women were analyzed separately. Results are presented
as odds ratios with the 95% confidence interval in
uni and multivariate analyses. All analyses were
performed using the statistical software SAS version
9.1 (SAS Institute Inc., Cary, NC, USA). The study
was approved by the Regional Ethical Review Board
in Stockholm.
Results
The characteristics of the women participating are
shown in Table I. The median age was 30.0 years
(range 1644 years) and the mean W-DEQ score was
62.8 (SD 23.3). The W-DEQ score was normally
distributed in the population. The number of
women with intense fear of childbirth (W-DEQ
score ]85) was 254 (15.6%). The number of
women with very intense fear of childbirth (tocophobia) (W-DEQ score ]100) was 93 (5.7%).
There was no difference in the distribution of
W-DEQ A score according to place of residence.
Nulliparous women had a higher mean W-DEQ
score (64.5, SD 21.6) compared with parous women
(60.7, SD 24.9) p 0.0009). On the other hand, a
larger proportion of parous women (16.5%) scored
]85 compared with nulliparous women (14.8%).
There was no correlation between level of fear and
gestational age ( p 0.47).
Parous women (n 128), who previously had a
cesarean section were more likely to have a higher
mean W-DEQ score compared to women with a
previous vaginal delivery (76.6 and 57.5, respectively, p B0.0001). Women who had previously
experienced a vacuum extraction or forceps delivery
(n 118) were more afraid of their delivery compared with parous women with no experience in
instrumental delivery (mean W-DEQ 65.6 and 59.5,
respectively, p B0.02).
According to the multivariate analysis for nulliparous women (Table II), there was no association
between maternal education and marital status with
fear of childbirth (W-DEQ ]85). Compared with
women between 25 and 29 years, women with higher
maternal age were at increased risk of intense fear of
childbirth.
Among parous women (Table III), a previous
cesarean section was the only factor which significantly predicted fear of childbirth (OR 3.38, 2.13
5.38) in the multivariate analysis. In this study,
7.3% of pregnant women stated that they would
Fear of childbirth and preference for cesarean
809
Table I. Characteristics of pregnant women participating in the study and mean W-DEQ-score, Sweden 2006.
Characteristic
No. of women
N1,635
Percent
Mean W-DEQ (SD)
62.8 (23.3)
Age (yr)
1524
2529
3034
]35
Data missing
220
480
603
320
12
13.6
29.6
37.2
19.7
62.7
61.6
64.3
61.7
Parity
0
]1
Data missing
861
769
5
52.8
47.2
64.5 (21.6)
60.7 (24.9)
Education (yr)
511
]12
Data missing
811
817
7
49.8
50.2
62.9 (23.8)
62.8 (23.0)
1,561
63
11
96.1
3.9
62.7 (23.4)
64.5 (22.3)
522
450
174
489
31.9
27.5
10.6
29.9
64.0
62.5
62.3
61.9
Living with the baby’s father
Yes
No
Data missing
Place of residence
Stockholm
Norrköping
Motala
Helsingborg
p-Value*
0.22
(21.1)
(22.9)
(24.1)
(24.0)
0.0009
0.93
0.55
0.49
(23.0)
(24.3)
(24.5)
(22.4)
*ANOVA-test.
vaginal delivery (n 1,503, W-DEQ score 60.6,
pB0.0001). There was no significant difference in
preference of cesarean section between the various
prefer to give birth with a cesarean section. These
women (n 119) had a higher mean W-DEQ score
(88.8) in comparison with women who preferred
Table II. Adjusted odds ratios for intense fear of childbirth measured as W-DEQ]85 among 861 nulliparous women in Sweden, 2006.
Intense fear of childbirth
W-DEQ]85
Yes
No
No. of women
No. of women
Odds ratio
(127)
(734)
(95% CI)
Age (yr)
1524
2529a
3034
]35
Data missing
25
33
54
15
153
268
223
88
2
1.30 (0.732.32)
1.00
2.06 (1.283.33)
1.42 (0.742.74)
Education (yr)
511a
]12
Data missing
61
66
348
380
6
1.00
0.84 (0.561.28)
Living with the baby’s father
Yesa
No
Data missing
124
3
698
34
2
1.00
0.51 (0.151.71)
Characteristic
p-Value*
0.029
0.42
0.28
*Wald test for the general effect (test of general heterogeneity).
a
The women with this characteristic served as the reference group.
810
K. Nieminen et al.
Table III. Adjusted odds ratios for intense fear of childbirth measured as W-DEQ ]85 among 769 parous women in Sweden, 2006.
Intense fear of childbirth
W-DEQ]85
Yes
No
No. of women
No. of women
Odds ratio
(127)
(642)
(95% CI)
Age (yr)
1524
2529a
3034
]35
Data missing
6
26
58
35
2
36
150
266
182
8
0.93 (0.322.66)
1.00
1.19 (0.702.03)
0.96 (0.531.74)
Education (yr)
511a
]12
Data missing
67
59
1
330
312
1.00
0.99 (0.641.52)
118
8
1
616
18
8
1.00
2.10 (0.805.52)
Previous cesarean section
Yes
Noa
Data missing
43
80
4
85
544
13
3.38 (2.135.38)
1.00
Previous instrumental delivery
Yes
Noa
Data missing
21
98
8
97
526
19
1.30 (0.742.26)
1.00
Characteristic
Living with the baby’s father
Yesa
No
Data missing
p-Value*
0.82
0.95
0.13
B0.0001
0.36
*Wald test for the general effect (test of general heterogeneity).
a
The women with this characteristic served as the reference group.
geographic areas. The 119 women who preferred a
cesarean section consisted of 44 women with at least
one previous section, seven women with a previous
instrumental vaginal delivery, six women with both a
cesarean and an instrumental vaginal delivery, 15
parous women with no reported instrumental births
(but there may have been other complications), and
47 women who had never given birth. In a multivariable analysis of the group of nulliparous women
(Table IV), fear of vaginal birth was the only factor
which predicted preference for cesarean section (OR
11.79, 6.122.59). There was a tendency that
education longer than 12 years reduced the preference for cesarean section p0.052). Among
parous women (Table V), the factors contributing
to the preference for a cesarean section were fear of
childbirth (OR 8.32, 4.3615.85), previous cesarean
section (OR 18.54, 9.5535.97), and previous instrumental delivery (OR 2.34, 1.025.34).
In the study population there was a small group of
pregnant women (3.1%) who preferred to be deliv-
ered by cesarean section despite their W-DEQ scores
of B85 indicating that they were not severely afraid
of the delivery. These women (19 nulliparous and 31
parous) had a higher mean W-DEQ score (65.3)
compared with those without severe fear who preferred a vaginal delivery (n 1,325) 55.5, p
B0.0001. In all, 2.2% of the nulliparous women
and 4.0% of the parous women would prefer a
cesarean section in spite of no intense fear of
childbirth according to the W-DEQ.
Discussion
This study shows a high prevalence of intense fear of
childbirth. The mean W-DEQ scores are higher than
in previous Swedish studies published in 1998 and
2001 (2,12). We did not see any correlation between
level of fear of childbirth and length of pregnancy,
which indicates that it is possible to use the W-DEQ
throughout pregnancy with the same norm values. A
recent Danish study (14) also did not find any
Fear of childbirth and preference for cesarean
811
Table IV. Adjusted odds ratios for preference of cesarean section among 861 nulliparous women in Sweden, 2006.
Preference of cesarean section
Yes
No
No. of women
No. of women
Odds ratio
(47)
(812)
(95% CI)
Age (yr)
1524
2529a
3034
]35
Data missing
11
12
16
7
1
166
289
260
96
1
1.18 (0.463.04)
1.00
1.37 (0.593.19)
1.73 (0.614.91)
Education (yr)
511a
]12
Data missing
29
17
1
379
428
5
1.00
0.49 (0.241.01)
Living with the baby’s father
Yesa
No
Data missing
45
2
775
35
2
1.00
1.33 (0.286.37)
W-DEQ]85
Yes
Noa
28
19
98
714
11.79 (6.1622.59)
1.00
Characteristic
p-Value*
0.76
0.052
0.72
B0.0001
*Wald test for the general effect (test of general heterogeneity).
a
The women with this characteristic served as the reference group.
difference between the number of women who
reported fear of birth in weeks 16 and 32. As our
study is cross-sectional, we cannot say whether there
is an interpersonal variation in the level of fear
during pregnancy.
We could not show any significant difference in
prevalence of fear, or in the wish to have a cesarean
section, between the different subsamples representing towns of different sizes; this is interesting to note,
as the cesarean section ratio is often higher in big
cities. Older nulliparous women more often reported
fear of childbirth. Perhaps, older nulliparous women
in Sweden are more used to planning and structuring
their lives in detail. They may be influenced by the
image projected in modern society that everything
can be controlled, whereas childbirth is in many
respects an uncontrollable event.
Nulliparous women had a higher mean W-DEQ
score than parous women in general, as shown in
most previous studies (12,15), though not in the
previous Helsingborg study (2). However, parous
women more often qualified for the designation of
intense fear of childbirth. This is not surprising
according to clinical experience. Women pregnant
for the first time tend to be a bit more anxious about
the unknown situation of birth, but the women who
need to consult a fear of childbirth team (16) are
70% women with traumatic birth experiences.
This study confirms what several previous studies
have demonstrated, i.e. the influence of an operative
delivery on parous women’s fear of childbirth
(17,18). In this anonymous study, we did not have
access to medical records, and we do not know
whether fear of childbirth was more common after a
previous emergency cesarean section than after an
elective one. Women without a primary fear of
childbirth may be traumatized by a birth interrupted. Symptoms of post-traumatic stress disorder
following childbirth are more common after an
emergency cesarean section than after other types
of birth (19). It is important to identify women with
adverse experiences of delivery. In particular, resources should be allocated for the diagnosis and
treatment of post-traumatic stress disorder following
childbirth (20).
This study also shows that 7.3% of the sample
would prefer a cesarean section to a vaginal delivery.
This is about the same percentage as in the Swedish
study by Hildingsson et al. (21), based on data
collected in 1996. It is notable that many more
women (17% in 2005) in Sweden have to undergo a
cesarean section, in many cases in an emergency
(22).
There has been a lively debate about whether it is
justified to perform cesarean section on maternal
request (23). We identified a small group of women
who wanted a cesarean section but, according to the
812
K. Nieminen et al.
Table V. Adjusted odds ratios for preference of cesarean section among 769 parous women in Sweden, 2006.
Preference of cesarean section
Yes
No
No. of women
No. of women
Odds ratio
(72)
(691)
(95% CI)
Age (yr)
1524
2529a
3034
]35
Data missing
3
17
27
24
1
39
157
296
190
9
1.01 (0.224.69)
1.00
0.69 (0.301.55)
1.08 (0.452.59)
Education (yr)
511a
]12
Data missing
44
27
1
348
343
1.00
0.56 (0.281.09)
Living with the baby’s father
Yesa
No
Data missing
70
2
660
22
9
1.00
0.37 (0.034.37)
Previous cesarean section
Yes
Noa
Data missing
50
22
77
597
17
18.54 (9.5535.97)
1.00
Previous instrumental delivery
Yes
Noa
Data missing
13
55
4
104
565
22
2.34 (1.025.34)
1.00
W-DEQ]85
Yes
Noa
41
31
84
607
8.32 (4.3615.86)
1.00
Characteristic
p-Value*
0.65
0.089
0.43
B0.0001
0.045
B0.0001
*Wald test for the general effect (test of general heterogeneity).
a
The women with this characteristic served as the reference group.
screening instrument W-DEQ A, were not intensely
afraid of childbirth. The group sum score of these
women indicates a moderate fear of childbirth.
Obviously, there are other things than fear alone
that influence the wishes of some women. Social
factors may be important, and also personality
variables, as shown by Wiklund et al. (24). In this
study we did not control for previous sexual abuse or
for the pregnant women’s mental health, factors that
can also influence the prevalence of intensive fear of
childbirth and/or the preference for cesarean section
(25,26). However, fear of vaginal birth seems to be
the most important factor that influences a nulliparous woman to demand a cesarean section, as also
shown by Wiklund et al. (10). Some of the parous
women who preferred a cesarean section may also
have had medical reasons, such as two previous
cesarean sections.
A limitation of our study is that it is not
representative of the whole country (as compared
with the one conducted by Waldenström et al.
(11,14)). The sample in our study is regarded as
socio-demographically representative only of pregnant Swedish-speakers in the four areas investigated
as 98% of pregnant women participate in a national
antenatal care program.
According to the Swedish Birth Register 2006,
including non-Swedish speakers, the average age of
giving birth was 30.3 years (nulliparous 28.5, parous
31.8 years) and 44% of the women who gave birth
were nulliparous (22.) The discrepancy in parity
may be due to Swedish-speaking women tending to
have fewer children than recent immigrants from
countries with a high birth rate. Very few women
declined to participate. We believe that the short
simple questionnaire, completed before leaving the
Fear of childbirth and preference for cesarean
clinic, and the anonymous nature of the study is one
explanation for this; another is that the questionnaire
was handed over by the pregnant women’s personal
antenatal care midwife, a person in whom women
have much confidence. A study of immigrant women’s expectations and fears of childbirth would be
interesting, since these women have always been
excluded from this area of research.
A possible source of error is that a woman who
knows that she must have a cesarean section for
medical reasons, may have difficulties in completing
the W-DEQ, which is about expectations of a vaginal
delivery.
In conclusion, fear of childbirth seems to be as
frequent in early as in mid or late pregnancy. There
is a clear correlation between fear of childbirth and
preference for a cesarean section. The W-DEQ that
was used in this study was well accepted by patients
and few refused to participate. The questionnaire
can be used at any time during pregnancy in order to
find pregnant women who suffer from fear of childbirth. We suggest a randomized trial of cognitive
behavioral therapy for intense fear of childbirth.
9. Vladic Stjernholm Y. Increased number of caesarean sections
without medical indications in spite of the risks. Lakartidningen. 2007;104:9425.
10. Wiklund I, Edman G, Ryding EL, Andolf E. Expectations
and experiences of childbirth in primiparae with caesarean
section. BJOG. 2007;115:32431.
11. Waldenström U, Hildingsson I, Ryding EL. Antenatal fear of
childbirth and its association with subsequent caesarean
section and experience of childbirth. BJOG. 2006;113:
63846.
12. Zar M, Wijma K, Wijma B. Pre- and postpartum fear of
childbirth in nulliparous and parous women. Scand J Beh
Therapy. 2002;30:7584.
13. Zar M, Wijma K, Wijma B. Relation between anxiety
disorders and fear of childbirth during late pregnancy. Clin
Psychol Psychother. 2002;9:12230.
14. Laursen M, Hedegaard M, Johansen C. Danish National
Birth Cohort. Fear of childbirth and temporal changes among
nulliparous women in the Danish National Birth Cohort.
BJOG. 2008;115:3546.
15. Johnson RC, Slade P. Does fear of childbirth during
pregnancy predict emergency caesarean section? BJOG.
2002;109:121321.
16. Ryding EL, Persson Å, Onell C, Kvist L. An evaluation of
midwives’ counselling of pregnant women in fear of childbirth. Acta Obstet Gynecol Scand. 2003;82:107.
17. Saisto T, Ylikorkala O, Halmesmäki E. Factors associated
with fear of childbirth in second pregnancies. Obstet Gynecol.
1999;94:67982.
18. Ryding EL, Wirfelt E, Wängborg I-B, Sjögren B, Edman G.
Personality and fear of childbirth. Acta Obstet Gynecol
Scand. 2007;86:11420.
19. Ryding EL, Wijma K, Wijma B. Psychological impact of
emergency cesarean section in comparison with elective
cesarean section, instrumental, and normal vaginal delivery.
J Psychosom Obstet Gynecol. 1998;19:13544.
20. Ayers S, Joseph S, McKenzie-McHarg K, Slade P, Wijma K.
Post-traumatic stress disorder following childbirth: current
issues and recommendations for future research. J Psychosom
Obstet Gynaecol. 2008;28:111.
21. Hildingsson I, Rådesta I, Rubertsson C, Waldenström U. Few
women wish to be delivered by caesarean. BJOG. 2002;109:
61823.
22. Official Statistics of Sweden: Graviditeter. förlossningar och
nyfödda barn Medicinska födelseregistret 19732006 [Pregnancies, deliveries and newborn infants. The Medical Birth
Register 19732006] 2008. ISBN: 978-91-85999-39-2. Available online at: http://www.socialstyrelsen.se/NR/rdonlyres/
70A20A7A-F6A9-45DE-97FC-7BF15BFE299C/12347/
2008425_rev2.pdf
23. Lavender T, Hofmeyr GJ, Neilson JP, Kingdon C, Gyte GM.
Caesarean section for non-medical reasons at term. Cochrane
Database Syst Rev. 2006;3:CD004660.
24. Wiklund I, Edman G, Larsson C, Andolf E. Personality and
mode of delivery. Acta Obstet Gynecol Scand. 2006;85:
122530.
25. Heimstad R, Dahloe R, Laache I, Skogvoll E, Schei B. Fear of
childbirth and history of abuse: implications for pregnancy
and delivery. Acta Obstet Gynecol Scand. 2006;85:43540.
26. Andersson L, Sundström-Poromaa I, Bixo M, Wulff M,
Bondestam K, .Åström M. Point prevalence of psychiatric
disorders during the second trimester of pregnancy:
a population-based study. Am J Obstet Gynecol. 2003;189:
14854.
/
/
/
/
/
/
/
/
/
/
/
/
References
/
/
1. Areskog B, Uddenberg N, Kjessler B. Experience of women
with and without antenatal fear of childbirth. Gynecol Obstet
Invest. 1983;16:112.
2. Ryding EL, Wijma K, Wijma B, Rydhström H. Fear of
childbirth during pregnancy may increase the risk of emergency cesarean section. Acta Obstet Gynecol Scand. 1998;77:
5427.
3. Andersson L, Sundstrom-Poromaa I, Bixo M, Wulff M,
Bondestam K, Strom M. Point prevalence of psychiatric
disorders during the second trimester of pregnancy: a
population-based study. Am J Obstet Gynecol. 2003;189:
14854.
4. Glover V, O’Connor TG. Effects of antenatal stress and
anxiety: implications for development and psychiatry. Br J
Psychiatry. 2002;180:38991.
5. Wijma K, Wijma B, Zar M. Psychometric aspects of the WDEQ: a new questionnaire for the measurement of fear of
childbirth. J Psychosom Obstet Gynecol. 1998;19:8497.
6. Sjögren B. Fear of childbirth and psychosomatic support.
A follow-up of 72 women. Acta Obstet Gynecol Scand. 1998;
77:81925.
7. Saisto T, Salmela-Aro K, Nurmi J-E, Könönen T, Halmesmäki E. A randomized controlled trial of intervention in fear
of childbirth. Obstet Gynecol. 2001;98:8206.
8. Saisto T, Halmesmäki E. Fear of childbirth can be treated,
and cesarean section on maternal request avoided. Acta
Obstet Gynecol Scand. 2007;86:11489.
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible for the content and writing of the paper.
/
813
/
/
/
/
/
/
/
/
/
/
/
/
/