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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 / / / / / / / / / / / / /