Fear of Childbirth during Pregnancy and Birth Planning

doi:10.21203/rs.3.rs-4713231/v1

Download PDF

Article

Fear of Childbirth during Pregnancy and Birth Planning

https://doi.org/10.21203/rs.3.rs-4713231/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

Pregnancy is a period during which a woman experiences numerous hormonal, psychological, physiological, and social changes. Those changes may lead to increased anxiety, and in some cases, the development of mental health disorders. Childbirth anxiety, first described by Louis Victor Marcé, may significantly impact the daily life of pregnant women. The term "tokophobia" refers to an irrational fear of childbirth. That anxiety may increase the risk of perinatal complications and influence decisions regarding the mode of delivery, such as leading to a rise in the number of cesarean sections. Medical staff, especially midwives and obstetricians, play a crucial role in alleviating childbirth anxiety through prenatal education and emotional support.

Methods

The study was conducted among 208 pregnant women in their second and third trimesters. It was a cross-sectional study carried out from January to April 2024 by means of an online survey. A high-risk pregnancy was the exclusion criterion. The survey included a survey questionnaire and the Childbirth Anxiety Questionnaire by Putyński and Paciorek, that is the Polish Adaptation of the Pregnancy-Related Anxiety Questionnaire – Revised 2 and the the Mini-Cope Inventory for Measuring Coping with Stress.

Results

Most of the women surveyed had a higher educational background, were married, and lived in large cities. For 62% of the women, it was their first pregnancy, and less than a half of the women who had previously given birth had done so naturally. Most women expressed a preference for vaginal delivery. Women who already had one child and those who had seen a psychologist, psychiatrist, or psychotherapist during pregnancy were more likely to opt for a cesarean section. Attending childbirth classes during the pregnancy did not affect the level of anxiety experienced by the women. Women who had not decided on the mode of delivery experienced higher levels of anxiety and worry as compared to those who chose vaginal delivery. Women with a history of mental health issues experienced greater anxiety during their pregnancy than those without such issues.

Conclusions

Medical personnel play a crucial role in reducing childbirth anxiety through education and emotional support. Early detection of high levels of childbirth anxiety by means of screening tests may help in reducing anxiety and its impact on both the mother and the child.

Biological sciences/Psychology/Human behaviour

Health sciences/Health care

Labor

anxiety

birth planning

childbirth

Pregnancy is a period during which a woman experiences many hormonal, psychological, physiological, and social changes [1]. It often intensifies anxiety and may even lead to the development of mental illness [2]. Anxiety is a psychobiological process that causes changes at the cognitive, behavioural, and physiological levels and is perceived as a warning signal against danger and immediate threat. According to the World Health Organisation (WHO), the risk of depression is higher in pregnant women suffering from anxiety disorders. Additionally, increased levels of anxiety in pregnant women are associated with a higher frequency of perinatal complications for both the mother and the child, and may also lead to premature birth and lower birth weight of the child [3,4].

The anxiety experienced by pregnant women may be specifically related to childbirth itself. It was first described by French psychiatrist Louis Victor Marcé and was precisely characterised in 1981 as ‘intense fear that disrupts women's daily life and well-being’ [5]. Tokophobia is a commonly used term that refers to an irrational fear of childbirth in women [6]. As a result, the fear of childbirth is associated with the increasing number of performed cesarean sections – both emergency and planned [7].

A significant role in alleviating the childbirth fear and preparing pregnant women for childbirth is played by medical personnel, primarily midwives and obstetricians. In Poland, pregnant women may take advantage of free prenatal education offers, such as childbirth classes and weekly meetings with community midwives. Thanks to those opportunities, pregnant women may gain knowledge about pregnancy and childbirth, ask questions that concern them, visit the delivery room where they plan to give birth beforehand, and acquire essential skills for coping with labour pain, which may provoke fear and anxiety [8,9]. Preparation for childbirth was particularly emphasised by Grantly Dick-Read, and the popular "fear-tension-pain" triad was named after him. He argued that it was precisely the preparation for childbirth that allowed for the elimination of that triad during labour [10].

In effect of a review of 18 scientific studies, the authors concluded that effective methods for reducing the childbirth fear included prenatal education, psychoeducation, counselling, and cognitive-behavioural therapy [11]. Factors that may alleviate the fear of childbirth also include emotional support, focusing on positives, obtaining information, and planning ahead [12].

According to Lazarus and Folkman's theory, coping with stress arises from the relationship between the individual and their environment, and the individual's appraisal of those events. Coping with stress involves various strategies - emotion-oriented (such as avoidance, escape, acceptance) and problem-oriented (seeking support or information) [13]. Pregnant women, as a coping strategy for dealing with stress, point to choosing appropriate medical facilities, acquiring knowledge about childbirth, avoiding sources of stress such as negative memories related to childbirth, paying more attention to themselves and their needs, preparing for childbirth, and spiritual contemplation [14].

The aim of the presented research is to assess the level of anxiety in pregnant women, identify factors related to experiencing anxiety, understand the influence of anxiety on the childbirth planning process, and determine coping strategies for fear and stress before childbirth. The following research hypotheses have been formulated for the study purpose:

A higher level of childbirth anxiety is associated with planning to undergo a cesarean section.
Participation in childbirth education classes reduces the level of childbirth anxiety.
Women who have experienced anxiety or depressive disorders in the past exhibit higher levels of childbirth anxiety.

Participants

The study was conducted among a group of pregnant women in the second and third trimesters of pregnancy. The study group consisted of 208 pregnant women.

Study Design and Data Collection

The cross-sectional study was conducted from January to April 2024 through an online survey created by means of the Google Forms software. Invitations to participate in the study were sent to pregnant women via social media. All respondents were Polish. Being in the second or third trimester of pregnancy was among the inclusion criteria. A high-risk pregnancy was the exclusion criterion.

Participation in the study was voluntary. The research was anonymous, and each participant could withdraw from the study at any time. Joining the study was equivalent to giving consent to participate in the research.

Measures

In the study, a diagnostic survey method was followed, employing the following research tools:

The self-constructed questionnaire (29 questions) incorporating metric data (7 questions) addressing the following aspects: Previous childbirth experience, Participation in childbirth education, Evaluation of support and care from close individuals and medical staff, Birth plan, Participation in therapy in the past, Psychiatric treatment history, Smoking and alcohol consumption during pregnancy, Subjective assessment of anxiety and distress (rated on a scale from 1 to 5, where 1 indicates no anxiety, 2 indicates mild anxiety, 3 indicates moderate anxiety, 4 indicates severe anxiety, and 5 indicates very severe anxiety), Health status assessment (rated on a scale from 1 to 5, where 1 indicates very good health, 2 indicates rather good health, 3 indicates moderate health problems, 4 indicates significant health problems, and 5 indicates very significant health problems)
The Childbirth Anxiety Questionnaire by Putyński and Paciorek [15]
The Polish Adaptation of the Pregnancy-Related Anxiety Questionnaire – Revised 2 (PRAQ – R2) [16,17]
The Mini-Cope Inventory for Measuring Coping with Stress [18]

The Childbirth Anxiety Questionnaire by Putyński and Paciorek (KLP II) is a research tool consisting of nine statements. For each statement, the respondent chooses one of four categories: strongly agree, agree, disagree, strongly disagree. Each category is assigned a numerical value from 0 to 3 - statements 2, 3, and 5 have values from 0 to 3, while statements 1, 4, 6, 7, 8, and 9 have values from 3 to 0. Scores may range from 0 to 27 points. Scores up to 13 points indicate low childbirth anxiety, 14 - 15 points suggest slightly elevated anxiety, 16 - 17 points indicate high anxiety, and scores above 18 points indicate very high childbirth anxiety. [15].

The Polish Adaptation of the Pregnancy-Related Anxiety Questionnaire – Revised 2 (PRAQ-R2) is a research tool used for assessing anxiety related to pregnancy. It includes three dimensions: the fear of childbirth, concern about having a disabled child, and worry about one's own appearance. It consists of 10 statements. Respondents choose one out of five responses: 1 – strongly disagree, 2 – disagree, 3 – undecided, 4 – agree, 5 – strongly agree. A higher score indicates a higher level of childbirth anxiety [16,17].

Mini – Cope The 10-item Mini-Cope Inventory for Measuring Coping with Stress is a research tool consisting of 28 statements that correspond to typical ways respondents react to difficult or stressful events. The inventory identifies strategies such as active coping, seeking support, avoidance, helplessness, turning to religion, acceptance, and humour. Participants indicate their response to each statement using one out of four options, scored as follows: ‘almost never’ (0 points), ‘rarely’ (1 point), ‘often’ (2 points), and ‘almost always’ (3 points). Each strategy is assessed separately based on the average score obtained from two statements assigned to it [18].

ETHICS CONSIDERATION The research was carried out in accordance with the Declaration of Helsinki and Good Clinical Practice in research. Bioethics Committee of the Medical University in Bialystok, Poland granted the ethical approval for the study (APK.002.461.2023.). Participation was voluntary and participants were informed about the project.

STATISTICAL ANALYSIS

In order to answer the research questions and test the hypotheses, statistical analyses were conducted by means of IBM SPSS Statistics version 29. The following analyses were performed: basic descriptive statistics were computed to summarise the data, Fisher-Freeman-Halton exact tests, the chi-square tests, independent samples t-tests were conducted to compare means between two independent groups, the Mann-Whitney U test and Kruskal-Wallis test as well as the Spearman's rho correlation analysis. The statistical significance level was set at the conventional threshold of α = 0.05.

Study Group Profile

In this study 208 pregnant women participated. The majority of them were respondents within the age range of 22 to 30 years (59.1%) and 31 to 40 years (31.7%). A half of the respondents (50%) had completed a master's degree, while 19.2% had completed a bachelor's or engineering degree, and more than one-fourth of the group (27.4%) had completed secondary education. Additional details are presented in Table 1.

The majority of women (87%) were married or in a relationship. Nearly a half of them (43.8%) lived in large cities. The next largest group of women by number were those living in rural areas (28.8%).

Among those surveyed, slightly over a half (51%) were on sick leave or maternity leave during the study, while more than one-third (34.6%) were employed.

The majority of participants identified their socioeconomic status as average (71.3%). In terms of the number of children they had, 62% reported to have none (Table 1).

Table 1

*Sociodemographic data of the Study Group*
Tested Variable	N	%
Age
Under 22	15	7,2%
22–30	123	59,1%
31–40	66	31,7%
Over 40	4	1,9%
Educational Background
Primary Education	5	2,4%
Junior High School	2	1,0%
Secondary Education	57	27,4%
Bachelor’s/Engineering Degree	40	19,2%
Master’s Degree	104	50,0%
Marital Status
Single	24	11,5%
Married/in a relationship	181	87,0%
Divorced	3	1,4%
Residence
Rural Area	60	28,8%
A Town with population below 50 000 residents	36	17,3%
A Town with population from 50 000 to 100 000 residents	21	10,1%
A City with population over 100 000 residents	91	43,8%
Professional Engagement
Professionally Active	72	34,6%
On sick leave/Holiday	106	51,0%
Unemployment	25	12,0%
Student	5	2,4%
Socioeconomic Status
Low	3	1,4%
Average	148	71,2%
Very Good	57	27,4%
Children
None	129	62,0%
Yes, one	57	27,4%
Yes, two	16	7,7%
Yes, more than two	6	2,9%

Assessment of Somatic Condition

Participants generally rated their overall health (on a scale of 1–5) as rather good (41.8%) or very good (35.1%). On the other hand, 18.3% of women experienced moderate levels of health problems.

Among health problems, 26% of women had thyroid disorders, more than twice as many (10.6%) had diabetes, and 8.2% had musculoskeletal/orthopaedic disorders. A smaller percentage of women had hypertension (5.8%), kidney diseases (4.3%), heart diseases (2.4%), neurological disorders (1.9%), liver diseases (0.5%), and lung diseases (0.5%)).

Experience from Previous Birth

Among women who had given birth previously (n = 106), less than a half (43.4%) gave birth naturally. Overall, the majority did not have unpleasant or traumatic memories associated with childbirth (63.4%), although the remaining percentage share of participants reported such experience.

Most commonly, the participants experienced unpleasant comments from medical staff (61.5%), the lack of information (53.8%), the lack of care (33.3%), or the lack of respect for their dignity and/or privacy (30.8%). For 23.1% of women, traumatic experience included procedures performed without their consent. Additionally, 12.8% mentioned being intimidated or threatened by medical personnel, while the remaining 15.4% reported other traumatic memories associated with childbirth.

Experience from the Course of Pregnancy and Birth Planning

More than a half of the surveyed women (54.3%) did not attend childbirth education classes during their pregnancy. Among those who did attend, 39.9% did so regularly.

For the vast majority (77.4%), the support shown by their loved ones was sufficient. Similarly, 72.1% felt that medical staff provided answers to their pressing questions. Approximately a half of the respondents (51%) believed that the attitude of the medical staff caring for them during pregnancy helped reduce their fear of childbirth. However, 27.9% of women disagreed, while 21.2% did not have a clear opinion on that matter.

For the majority of women (67.6%), the hospital's level of referral was significant, although 13.2% of respondents were not aware of its importance. Apart from women planning home births, only 22.5% of pregnant women visited the delivery room where they intended to give birth. Additionally, over 40% had a birth plan prepared.

The majority of the surveyed women (68.8%) believed that theoretical preparation for childbirth had an impact on reducing the fear of childbirth.

A significant majority of women stated that during the pregnancy, they did not resort to smoking (90.9%) or alcohol (99%) in stressful situations.

When planning childbirth, the majority of women (74%) expressed a preference for a natural delivery. 14.9% opted for a cesarean section. Additionally, 1.4% of the group indicated home birth as their preferred method of delivery. At the same time, 9.6% of women had not yet made a decision.

In order to investigate whether the chosen method of childbirth was associated with the number of children, the Fisher-Freeman-Halton exact test was conducted due to the low cell counts (< 20%) in some categories. The test yielded a statistically significant result (p = 0.002). Comparisons showed that women who already had had one child were more likely to opt for a cesarean section than women who had no children at all. On the other hand, women with more than two children were more likely to choose home birth as compared to childless women or those with only one child - although those results should be interpreted cautiously due to the low number of women opting for home birth (Table 2).

Table 2

*The method of ending pregnancy and the number of children a woman had*
Childbirth Method	Number of Children								χ²(9)	p	V_c
	0		1		2		> 2
	N	%	N	%	N	%	N	%
Natural Delivery	102^a	79,1%	37^a	64,9%	12^a	75,0%	3^a	50,0%	23,55	0,002	0,30
CC	13^a	10,1%	16^b	28,1%	1^ab	6,3%	1^ab	16,7%
Home Birth	1^a	0,8%	0^a	0,0%	0^ab	0,0%	2^b	33,3%
No Decision	13^a	10,1%	4^a	7,0%	3^a	18,8%	0^a	0,0%

N - number of observations; χ² - result of the chi-square test; p - statistical significance; Vc - effect size indicator. Counts with different letter indices differ significantly at the level of p < 0.05.

In the next step, it was examined whether there was a relationship between a woman's psychological well-being and the planned method of completing the pregnancy. The result was statistically non-significant, indicating that the planned childbirth method was not dependent on having unpleasant or traumatic memories associated with past childbirth experience (Table 3).

Table 3

*The trauma associated with the previous childbirth and the choice of how to complete the pregnancy*
Childbirth Method	Trauma Associated with the Previous Childbirth				χ²(3)	p	V_c
	NO		YES
	N	%	N	%
Natural Delivery	41	69,5%	23	67,6%	5,35	0,116	0,25
CC	15	25,4%	5	14,7%
Home Birth	0	0,0%	2	5,9%
No Decision	3	5,1%	4	11,8%

The relationship between the method of completing pregnancy and whether the woman had visited a psychologist, psychotherapist, or psychiatrist during the pregnancy was also analysed. The test result was statistically significant, and the observed associations were of weak strength. Subsequent comparisons of column proportions indicated that women who opted for a cesarean section were more likely to have visited a psychologist, psychotherapist, or psychiatrist during pregnancy (Table 4).

Table 4

*The visit to a psychologist, psychotherapist, or psychiatrist and the choice of how to complete the pregnancy*
Childbirth Method	Odbycie The Visit to a Psychologist, Psychotherapist, or Psychiatrist?				χ²(3)	p	V_c
	NO		YES
	N	%	N	%
Natural Delivery	137^a	75,3%	17^a	65,4%	9,61	0,015	0,23
CC	22^a	12,1%	9^b	34,6%
Home Birth	3^a	1,6%	0^a	0,0%
No Decision	20^a	11,0%	0^a	0,0%

Annotation

Counts with different letter indices differ significantly from each other at p < 0.05 level.

Assessment of Mental Health Status

More than one-third of the participants had been diagnosed with psychiatric disorders in the past, including anxiety and/or depressive disorders, and a comparable group reported undergoing therapy. One-fourth of pregnant women (25.5%) had previously visited a psychiatrist due to anxiety or depressive disorders. However, in the pregnancy under consideration, a small percentage share of the participants (12.5%) declared to have visited a psychologist, psychotherapist, or psychiatrist.

The average intensity of anxiety, rated on a scale of 1–5, was 2.88 (SD ± 1.1) (Table 5). More than one-third of women assessed their anxiety intensity as moderate, and over a quarter rated it as mild. However, as many as 18.8% reported strong or even very strong levels of anxiety (8.7%) (Table 5). The participants believed that the experienced anxiety was related to their pregnancy.

The analyses of coping strategies for stress (Mini-Cope) as well as anxiety related to pregnancy (PRAQ-R2) and childbirth anxiety (KLP II) showed the distribution close to normal only for the pregnancy-related anxiety. For the other measures, the test results were statistically significant (p < 0.001), indicating some asymmetry in the distributions. However, that asymmetry was not significant, taking into consideration the skewness and kurtosis values did not exceed |2|. Due to that, provided the other assumptions were met, the parametric tests were used for the purpose of the analyses.

In terms of coping strategies with stress (Mini-COPE), the highest mean value was obtained for active coping (M = 2.12, SD ± 0.71). Pregnancy-related anxiety (PRAQ-R2) was at a moderate level (M = 27.75, SD ± 9.10), and the average score for childbirth anxiety (KLP II) indicated a slightly elevated level of anxiety (M = 15.04, SD ± 5.42) (Table 5).

Table 5

*The levels of perceived anxiety and distress, coping strategies with stress (Mini-COPE), pregnancy-related anxiety (PRAQ-R2), and childbirth anxiety (KLP II)*
Dependent Variable	M	Me	SD	Sk.	Kurt.	Min.	Maks.	D	p
Anxiety and Fear (1–5)	2,88	3,00	1,10	0,16	-0,59	1,00	5,00	0,18	< 0,001
Mini-COPE (0–3)
Active Coping	2,12	2,00	0,71	-0,60	-0,06	0,00	3,00	0,17	< 0,001
Planning	2,04	2,00	0,75	-0,58	-0,05	0,00	3,00	0,19	< 0,001
Venting	1,64	1,50	0,67	-0,28	0,06	0,00	3,00	0,19	< 0,001
PRAQ-R2 (10–50)
Pregnancy-related Anxiety	27,75	28,00	9,10	0,09	-0,52	10,00	49,00	0,04	0,200
KLP II (0–27)
Childbirth Anxiety	15,04	15,00	5,42	-0,28	-0,36	1,00	26,00	0,09	< 0,001

M - mean; Me - median; SD - standard deviation; Sk. - skewness; Kurt. - kurtosis; Min. - minimum value; Max. - maximum value; D - Kolmogorov-Smirnov test statistic; p - p-value for Kolmogorov-Smirnov test.

In the next step, it was decided to examine whether sociodemographic variables were associated with anxiety and distress. Due to the ordinal nature of all the metric variables, the non-parametric analysis was conducted by means of the Spearman's rho correlation coefficient. The results of the analysis are presented in Table 6. They did not show any statistically significant relationship between age, education, or having children and the experience of anxiety and distress in pregnant women.

Table 6

*Sociodemographic variables and experienced anxiety and distress*
	Experienced Anxiety and Distress
Variable	rho Spearmana	p
Age	0,04	0,544
Educational Background	-0,13	0,059
Children	-0,04	0,585

During the analysis, the efforts were also made to determine whether the anxiety experienced by women varied based on varied attitudes and behaviour related to pregnancy, as well as their mental health status. Due to significant numerical disparities between the compared groups, non-parametric tests were predominantly used, such as the Mann-Whitney U test and the Kruskal-Wallis test. However, in respect of the question regarding the attendance at childbirth education classes during the pregnancy, the independent samples t-test was conducted, which showed that attending childbirth education classes did not differentiate the level of anxiety experienced by women (p > 0.05). Subsequently, the intensity of anxiety and distress was compared based on received support, evaluation of medical staff, birth plan preferences, and hospital referral importance. The results are presented in Table 7.

From the analysis, it was found that the assessment of social support from close individuals did not differentiate the level of anxiety among the surveyed women. Although a statistically significant effect was observed for social support from medical staff, further post hoc comparisons using Dunn-Bonferroni tests did not reveal statistically significant differences. Statistically significant effects were also noted for anxiety based on the attitude of medical staff and the planned childbirth method. Both effects indicated moderate differences. Additionally, statistically significant differences were found in the intensity of anxiety and distress between women who planned to have a natural birth and those who had not yet made a decision. Women who had not made a decision experienced higher levels of anxiety and distress as compared to those who planned for a natural birth. However, the effect of hospital referral importance assessment was found to be statistically non-significant.

Table 7

*The intensity of anxiety and distress in relation to the assessment of social support, information, childbirth plan preferences, and evaluation of hospital referral importance*
Questions	Responses	Intensity of Anxiety and Distress		H(2)	p	η²
		Mean Rank	Me
Receiving support from close individuals	No (n = 21)	112,07	3,00	2,94	0,229	0,01
	Yes (n = 161)	100,93	3,00
	I don’t have a clue (n = 26)	120,50	3,00
Obtaining information from medical staff	No (n = 31)	113,31	3,00	6,04	0,049*	0,03
	Yes (n = 150)	98,74	3,00
	I don’t have a clue (n = 27)	126,41	3,00
The influence of medical staff attitudes during pregnancy on reducing childbirth anxiety	No (n = 58)	129,90^a	3,00	21,13	< 0,001	0,10
	Yes (n = 106)	87,37^b	3,00
	I don’t have a clue (n = 44)	112,28^ab	3,00
Planning the method of childbirth	Natural Birth (n = 157)	96,95^a	3,00	13,96	< 0,001	0,07
	CC (n = 31)	116,19^ab	3,00
	No Decision (n = 20)	145,63^b	3,00
The importance of the medical facility's level of reference in which the pregnant woman intends to give birth	No (n = 39)	96,40	3,00	0,64	0,725	< 0,01
	Yes (n = 138)	104,52	3,00
	I don’t know what that is (n = 27)	100,98	3,00

Annotation: n - group size, Me - median, H - test statistic, p - significance level; η² - effect size indicator; * - despite a significant effect, post hoc comparisons did not show significant differences. Mean ranks with different letter indices differ significantly at p < 0.05 level.

Next, the relationship between women's past mental health and the levels of anxiety/distress during the pregnancy under consideration was analysed (Table 8). The analysis showed that only undergoing therapy did not differentiate the intensity of anxiety among the surveyed women. For the other comparisons, the results were statistically significant, although the observed effects were relatively weak. In each case, women who had experienced past mental health issues reported experiencing greater anxiety during their pregnancy under consideration as compared to women without such issues.

Table 8

*The intensity of anxiety and distress based on women's mental health status*
Assessment of Mental Health Status	Responses	Intensity of Anxiety and Distress		Z	p	η²
		Mean Rank	Me
Having attended a visit to a psychologist, psychotherapist, or psychiatrist	Nie (n = 182)	100,31	3,00	-2,76	0,006	0,04
	Tak (n = 26)	133,85	4,00
Anxiety or depressive states in the pasti	Nie (n = 125)	93,70	3,00	-3,29	< 0,001	0,05
	Tak (n = 83)	122,70	3,00
Therapy with a psychologist or psychotherapist in the past	Nie (n = 141)	100,61	3,00	-1,40	0,161	0,01
	Tak (n = 67)	112,68	3,00
Attending visits to a psychiatrist due to anxiety or depressive states in the past	Nie (n = 155)	94,41	3,00	-3,01	0,003	0,04
	Tak (n = 53)	125,25	3,00
Smoking cigarettes due to stressful situations during pregnancy	Nie (n = 189)	100,63	3,00	-3,03	0,002	0,04
	Tak (n = 19)	142,97	3,00

Annotation: n - group size, Me - median, Z - test statistic, p - significance level; η² - effect size indicator.

In order to examine whether women who attended childbirth education classes differed in terms of anxiety levels related to childbirth and general pregnancy-related anxiety from those who did not attend, independent samples t-tests were conducted. The results indicated that attending childbirth education classes differentiated the level of pregnancy-related anxiety but not childbirth anxiety. Specifically, women who attended childbirth education classes reported higher levels of pregnancy-related anxiety as compared to those who did not attend (Table 9).

Table 9

*Assessment of anxiety intensity based on attendance at childbirth education classes*
	Did not Attend (n = 113)		Attended (n = 95)					95% CI
Dependent Variable	M	SD	M	SD	t	df	p	LL	UL	d Cohena
Pregnancy-related Anxiety (PRAQ-R2)	26,56	9,26	29,17	8,75	-2,08	206	0,039	-5,09	-0,13	0,29
Childbirth Anxiety (KLP II)	14,65	5,52	15,52	5,28	-1,15	206	0,250	-2,36	0,62	0,16

Stress Coping Strategies and Childbirth Education Classes Attendance

The analysis also examined differences in stress coping strategies (Mini-COPE): active coping, planning, and venting based on attendance at childbirth education classes. The results of the independent samples t-test are presented in Table 10. The comparison showed that attending childbirth education classes influenced the intensity of preference for active coping as a stress coping strategy. The mean analysis indicated that women who attended childbirth education classes during the pregnancy preferred that coping strategy more strongly than women who did not attend. However, no differences were observed between the groups for planning and venting as stress coping strategies.

Table 10

*Stress coping strategies based on attendance at childbirth education classes*
	Did not Attend (n = 113)		Attended (n = 95)					95% CI
Dependent Variable	M	SD	M	SD	t	df	p	LL	UL	d Cohena
Active Coping	2,04	0,74	2,24	0,64	-2,12	205	0,035	-0,40	-0,01	0,30
Planning	2,00	0,81	2,09	0,67	-0,95	206	0,342	-0,30	0,11	0,13
Venting	1,57	0,70	1,73	0,62	-1,73	206	0,085	-0,34	0,02	0,24

Our study addresses such an important and sensitive time for women as pregnancy and childbirth.

Childbirth anxiety, as mentioned earlier, may trigger a number negative consequences [3,4]. Medical staff play a significant role during prenatal visits in reducing anxiety levels. It's important to emphasise the importance of prenatal education as well as screening tests, such as assessing the risk of depression [19]. Implementing those measures would enable quick response from medical staff and implementation of appropriate actions to help reduce anxiety. Those actions could include educational discussions, providing support, recommending visits to specialists, starting cognitive-behavioural therapy, or as a last resort, initiating pharmacological treatment [20].

In our research, we have found that over one-third of respondents reported unpleasant, traumatising memories, with the most common being: unpleasant comments from medical staff, the lack of information from medical staff, and the lack of care from medical staff. In 2007, Venezuela became the first country to use the term ‘obstetric violence’ recognising it as a punishable form of violence against women. Its definition read as follows: „the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanised treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women” [21]. From the related literature, it is reported that women worldwide experience violence and the lack of respect, including restrictions on movement during childbirth, being forced to lie on their backs unnecessarily, routine episiotomies, and routine insertion of intravenous lines [22]. It has been shown that such negative childbirth experience is associated with tocophobia (fear of childbirth) and a history of violence [23]. The number of respondents experiencing obstetric violence is concerning, and it seems necessary to pay special attention to such behaviour of medical staff. Minimising the incidence of violence in delivery rooms may significantly reduce the anxiety experienced by pregnant women.

In the presented studies, no statistically significant association was found between having unpleasant, traumatic memories related to childbirth and the planned method of delivery. This may be due to the relatively small sample size. Many scientific studies suggest that traumatic birth experience influences tocophobia and increases the rate of cesarean sections [24]. It's interesting that in our own study, the majority of women have been found to plan to have a natural childbirth. However, in the subsequent analyses, it has turned out that women who already had had one child were more likely to opt for a cesarean section. One might speculate that for many women, natural childbirth was such a traumatic experience that they opted not to have more children. As other researchers indicate, negative childbirth experience may indeed influence reproductive plans [24]. It's also possible that those women had undergone an emergency cesarean section and did not want to attempt natural childbirth again due to traumatic memories.

In our study, it has been shown that less than a half of the respondents attended childbirth education classes. It remains intriguing why such a small number of women decide to participate in childbirth classes that are offered as free education to every pregnant woman. Perhaps this is due to distant locations of childbirth education centres, the lack of childcare during class times, or insufficient awareness about those opportunities. It is important for medical personnel to inform patients about the benefits of attending childbirth classes and to promote the importance of utilising those facilities. In our own study, it has also been demonstrated that women who had experienced higher levels of pregnancy-related anxiety were more likely to attend childbirth classes. Furthermore, women attending childbirth classes showed a stronger preference for active coping strategies to manage stress as compared to those who did not attend. Our findings suggest that women experiencing higher levels of stress tend to choose environments where they can reduce their anxiety through the contact with qualified medical professionals. In the majority of scientific publications by other researchers, it has been concluded that participation in childbirth education significantly reduces the fear of childbirth [25,26,27].

In many scientific studies conducted in Western countries, it has been shown that higher levels of anxiety and the fear of childbirth influence the decision to undergo a cesarean section [28,29]. In a Japanese scientific study, it has been demonstrated that individuals exhibiting higher levels of the fear of childbirth plan to give birth naturally [30]. In our own study, no association has been found between higher levels of anxiety and planning for a cesarean section. However, it has been shown that women who had not yet made a decision regarding their childbirth method exhibited higher levels of anxiety and distress as compared to those who had decided to give birth naturally. It seems reasonable to conclude that pregnant women who are still weighing the pros and cons between natural childbirth and cesarean section options may experience greater anxiety. It would be worthwhile to focus on those pregnant women who have not yet decided on their childbirth method and provide them with medical support – including psychological care where they can share their concerns and sources of anxiety, as well as obstetric care where medical staff may address their doubts and provide accurate information about childbirth. It is possible that such an approach could positively influence the decision to opt for natural childbirth, thereby effectively reducing the rate of planned cesarean sections.

Psychological issues such as anxiety disorders and depression are unfortunately becoming increasingly common. Many people still do not seek help due to the fear of stigma and shame. Pregnant women also point out the difficulty in accessing mental health care because of the challenge in admitting that they are not as happy as they feel they should be [31]. In Sweden, pregnant women experiencing the fear of childbirth may benefit from counselling programmes conducted by qualified midwives who provide care throughout the pregnancy. Additionally, those women have a clear access to obstetricians and psychologists, ensuring they receive comprehensive support [11]. In recent times, psychotherapy has gained a significant value in addressing anxiety and depressive disorders during pregnancy. That method effectively helps avoid pharmacological complications associated with antidepressant medications and supports pregnant women by providing effective ways to self-regulate thoughts and recognise negative and irrational thinking patterns, thereby reducing the level of experienced anxiety [32,33,34]. Despite the proven positive effects of psychotherapy during pregnancy, in many countries it is not widely implemented or recommended due to insufficient numbers of therapists and financial constraints that prevent access to that method [35]. In our own studies, it has been shown that women who attended a specialist related to mental health during their pregnancy under consideration, had a history of anxiety or depressive disorders, or had previously seen a psychiatrist for anxiety or depressive disorders, experienced higher levels of anxiety and distress as compared to those without such past issues who did not seek counselling from a psychologist, psychotherapist, or psychiatrist during their pregnancy under consideration. Additionally, women who planned to have a cesarean section more frequently visited a psychologist, psychiatrist, or psychotherapist during their pregnancy under consideration. Similarly, in Swedish studies involving a group of 936 pregnant women, those who receive psychotherapeutic assistance mostly prefer a cesarean section [36]. In Swedish studies involving a group of 422 women with tokophobia, it has also been demonstrated that past mental health issues significantly influence the choice of cesarean section delivery and affect depressive symptoms during pregnancy, too [11].

It is crucial to provide proper psychological care to pregnant women to minimise their feelings of anxiety and distress. Special attention should be given to pregnant women who have a history of mental disorders such as anxiety or depression. Implementing programmes within perinatal care, that offer psychological support, especially for women whose previous childbirth may have been traumatic or who have had a history of mental health disorders, would be valuable. That support could be provided by psychologists, psychotherapists, psychiatrists, and midwives as well as obstetricians. Such a comprehensive care has the potential to reduce the increasing rate of elective cesarean sections, which should not be routinely recommended to every patient experiencing higher levels of anxiety.

In summary, given the objectives of our study, we have found that the majority of women reported moderate levels of anxiety related to pregnancy. Hypothesis 1 has not been confirmed as no relationship has been found between higher levels of anxiety and planning for a cesarean section. However, it has been shown that women who had not yet decided on the mode of delivery experienced higher levels of anxiety and distress as compared to those who had chosen vaginal birth. We have also found that women who attended childbirth education classes more frequently exhibited higher levels of pregnancy-related anxiety. That does not confirm Hypothesis 2, according to which participation in childbirth education classes reduces anxiety levels. However, women attending those classes showed a stronger preference for active coping strategies as compared to those who did not attend such classes. As far as Hypothesis 3 is concerned, it has been confirmed that women who had experienced anxiety or depressive disorders in the past, and those who had sought help from a psychotherapist, psychologist, or psychiatrist for those reasons, had higher levels of anxiety during the pregnancy under consideration. Additionally, pregnant women planning for a cesarean section more frequently took advantage of the services of psychologists, psychotherapists, and psychiatrists. Those findings underscore the complex relationship between psychological factors, childbirth preparation, and anxiety during pregnancy, highlighting the importance of tailored psychological support and education in perinatal care.

Constraints of the Study

The presented studies have their limitations, which should be considered when interpreting the results. Firstly, these are cross-sectional studies based solely on self-assessment surveys. Although standardised research tools used in this study are sensitive instruments designed to detect various states and traits, all the responses focus on the respondents' subjective feelings rather than objective criteria, which poses a risk of false positive results. Secondly, the study was conducted online, which meant that researchers had no control over the group's representation (participation was voluntary, and pregnant women interested in the topic undertook to complete the survey via a Google form). It led to a significantly greater representation of individuals with the higher educational background, making it difficult to generalise the research findings in terms of the overall population.

Ethics approval and consent to participate

The research was carried out in accordance with the Declaration of Helsinki and Good Clinical Practice in research. Bioethics Committee of the Medical University in Bialystok, Poland granted the ethical approval for the study (APK.002.461.2023.). Participation was voluntary and participants were informed about the project. The research was anonymous, and each participant could withdraw from the study at any time. Joining the study was equivalent to giving consent to participate in the research. Informed consent was obtained from all the human participants.

Consent for publication

Not applicable

Competing interests

The authors declare no competing interests.

Funding

This project has been supported by the Medical University of Bialystok: B.SUB.24.233

Authors' contributions

Conceptualization, P.G. and M.S; data curation, P.G. and M.S.; formal analysis, M.S. investigation, P.G. and M.S.; methodology, P.G. and M.S.; project administration, M.S.; writing—original draft, P.G.; writing—review and editing, P.G and M.S. All authors have read and agreed to the published version of the manuscript.

Acknowledgements

The author would like to express appreciation for the kind cooperation of all study participants, without whom the study could not have been completed.

Data available statement

The datasets used and analysed during the current study available from the corresponding author on reasonable request.

Din ZU, Ambreen S., Iqbal Z., Iqbal M., Ahmad S.: Determinants of antenatal psychological distress in Pakistani women. Archives of Neuropsychiatry. 2016;53(2):152-7.
Yuksel F., Akin S., Durna Z.: Prenatal distress in Turkish pregnant women and factors associated with maternal prenatal distress. Journal of Clinical Nursing. 2014;23(1-2):54-64
Dominguez-Solis E., Lima-Serrano M., Lima-Rodriguez JS.: Non-pharmagological interventions to reduce anxiety in pregnancy, labour and postpartum: A systematic review. Midwifery. 2021;102 doi: 10.1016/j.midw.2021.103126
Grigoriads S., Graves L., Peer M., Mamisashvili L., Tomlinson G., Vigod SN., Dennis C., Steiner M., Brown C., Cheung A., Dawson H., Rector NA., Guenette M., Richter M.: Maternal Anxiety During Pregnancy and the Association With Adverse Perinatal Outcomes: Systematic Review and Meta-Analysis. The Journal of Clinical Psychiatry. 2018; 79(5):17r12011 doi: 10.4088/JCP.17r12011
Nilsson C., Hessman E., Sjöblom H., Dencker A., Jangsten E., Molberg M., Patel H., Sparud-Lundin C., Wigert H., Begley C.: Definitions, measurements and prevalence of fear of childbirth: a systematic review. BMC Pregnancy Childbirth. 2018;18(1):28.
Hofberg K, Brockington I.: Tokophobia: an unreasoning dread of childbirth. A series of 26 cases: The British Journal of Psychiatry: the journal of mental science. 2000;176(1):83–5.
O’Connell MA., Khashan AS., Leahy-Warren P., Stewart F., O’Neill SM.: Interventions for fear of childbirth including tokophobia. The Cochrane database of systematic reviews. 2021, 7;7(7): CD013321. doi: 10.1002/14651858.CD013321.pub2
Kwiatek M., Geca T., Biegaj-Fic J., Kwaśniewska A.: Szkoła rodzenia – profil pacjentek oraz wpływ zajęć na przebieg porodu i stan noworodka. Medycyna Ogólna I Nauki o Zdrowiu. 2011;17(46):111-115.
Araszkiewicz A., Plagens-Rotman K.: Edukacja przedporodowa jako przygotowanie kobiety do macierzyństwa. Pielęgniarstwo Polskie. 2020;3:174-178.
Olszynko-Gryn J., Ellis P., Gainty C.: ‘Drawing aside the curtain’: natural childbirth on screen in 1950s Britain. British journal for the history of science. 2017;50(3):473-493.
Hildingsson I., Rubertsson C.: Depressive symptoms during pregnancy and after birth in women living in Sweden who received treatments for fear of birth. Archives of Women's Mental Health. 2022;25(2):473-484.
Sandström L., Kaunonen M., Klemetti R., Raussi-Lehto E., Liisa Aho A.: Factors helping pregnant multiparas cope with fear of birth: A qualitative study. Midwifery. 2023;125:103803 doi: 10.1016/j.midw.2023.103803
Han L., Bai H., Lun B., Li Y., Wang Y., Ni Q.: The Prevalence of Fear of Childbirth and Its Association With Intolerance of Uncertainty and Coping Styles Among Pregnant Chinese Women During the COVID-19 Pandemic. Froniters in Psychiatry. 2022;13:935760 doi: 10.3389/fpsyt.2022.935760
Lebni JY., Farahani FK., Solhi M., Azar FE.: Causes and Grounds of Childbirth Fear and Coping Strategies Used by Kurdish Adolescent Pregnant Women in Iran: A Qualitative Study. Journal of Reproduction & Infertility. 2021;22(1):47-56.
Paciorek M., Putyński L.: Kwestionariusz Lęku Porodowego (KLP II) Wersja Zrewidowana : konstrukcja i właściwości psychometryczne. Acta Universitatis Lodziensis. Folia Psychologica. 2008; 12: 129-133.
Mikołajków A., Fuchs T., Małyszczak K.: Polska adaptacja Pregnancy-Related Anxiety Questionnaire – Revised 2 (PRAQ-R2). Psychiatria Polska. 2023;305:1-10.
Alnasheet AM., Abdulaal NA., Kamal N.: The Prevalence and Risk Factors of Pregnancy-Related Anxiety in Bahrain. Cureus. 2024; 16(4):e57404. doi: 10.7759/cureus.57404
Babiarczyk B., Ślezińska B., Jaksz-Recmanik E.: Radzenie sobie ze stresem przez opiekunów pacjentów objętych opieką Zespołu Domowej Opieki Paliatywnej. Medycyna Paliatywna. 2023;15(3):119-129.
Schetter C.D., Rahal D., Ponting C., Julian M., Ramos I., Hobel C.J., Coussons-Read M.: Anxiety in pregnancy and length of gestation: Findings from the healthy babies before birth study. Health psychology : official journal of the Division of Health Psychology, American Psychological Association. 2022;41(12):894-903.
Akgün M., Boz İ., Özer Z.:The effect of psychoeducation on fear of childbirth and birth type: systematic review and meta-analysis. Journal of Psychosomatic Obstetrics and Gynaecology.2019; 41(4), 253–265.
D’Gregorio RP.: Obstetric violence: a new legal term introduced in Venezuela. International Journal of Gynecology & Obstetrics. 2010;111(3):201-202.
Lokugamage U., Pathberiya SDC.: Human rights in childbirth, narratives and restorative justice: a review. Reproductive Health. 2017;14:17.
Annborn A., Finnbogadóttir HR.: Obstetric violence a qualitative interview study. Midwifery. 2022;105:103212. doi: 10.1016/j.midw.2021.103212
Dencker A., Nilsson C., Begley C., Jangsten E., Mollberg M., Patel H., Wigert H., Hessman E., Sjöblom H., Sparud-Lundin C.: Causes and outcomes in studies of fear of childbirth: A systematic review. Women and Birth. 2019;32:99-111.
Kuo T.C., Au H.K., Chen S.R., Chipojola R., Lee G.T., Lee P.H., Kuo S.Y. Effects of an integrated childbirth education program to reduce fear of childbirth, anxiety, and depression, and improve dispositional mindfulness: A single-blind randomised controlled trial. Midwifery. 2022;113:103438. doi: 10.1016/j.midw.2022.103438.
Demšar K., Svetina M., Verdenik I., Tul N., Blickstein I., Velikonja V.G. Tokophobia (fear of childbirth): Prevalence and risk factors. Journal of Perinatal Medicine. 2018;46:151–154. doi: 10.1515/jpm-2016-0282
Rúger-Navarrete A., Vázquez-Lara J.M., Antúnez-Calvente I., Rodríguez-Díaz L., Riesco-González F.J., Palomo-Gómez R., Gómez-Salgado J., Fernández-Carrasco F.J.: Antenatal Fear of Childbirth as a Risk Factor for a Bad Childbirth Experience. Healthcare. 2023;11(3):297.
Faisal I., Matinnia N., Hejar A., Khodakarami Z.: Why do primigravidae request caesarean section in a normal pregnancy? A qualitative study in Iran. Midwifery. 30:227–233. doi:10.1016/j.midw.2013.08.011
Coates D., Thirukumar P., Spear V., Brown G., Henry A.: What are women’s mode of birth preferences and why? A systematic scoping review. Women Birth. 2020; 33 323–333. 10.1016/j.wombi.2019.09.005
Takegata M., Haruna M., Morikawa M., Yonezawa K., Komada M., Severinsson E.: Qualitative exploration of fear of childbirth and preferences for mode of birth among Japanese primiparas. Nursing & Health Sciences. 2018;20: 338–345.
Nagle U., Farrelly M.: Women’s views and experiences of having their mental health needs considered in the perinatal period. Midwifery. 2018; 66:79–87.
Dubovicky M., Belovicova K., Csatlosova K., Bogi E.: Risks of using SSRI / SNRI antidepressants during pregnancy and lactation. Interdisciplinary Toxicology. 2017;10:30–34.
Stoll K., Swift E.M., Fairbrother N., Nethery E.,Janssen P.: A systematic review of nonpharmacological prenatal interventions for pregnancy-specific anxiety and fear of childbirth. Birth.2018; 45:7–18.
Silverstein M, Feinberg E, Cabral H, Sauder S, Egbert L, Schainker E, Kamholz K, Hegel M., Beardslee W.: Problem-solving education to prevent depression among low-income mothers of preterm infants: A randomized controlled pilot trial. Archives of Women's Mental Health. 2011;14:317–324.
Beck A, Nadkarni A., Calam R., Naeem F., Husain N: Increasing access to Cognitive Behaviour Therapy in Low and Middle Income Countries: A strategic framework. Asian Journal of Psychiatry.2016; 22:190–195.
Larsson B., Karlström A., Rubertsson C., Hildingsson I.: The effects of counseling on fear of childbirth. Acta Obstetricia et Gynecologica Scandinavica. 2015;94(6):629-636.

No competing interests reported.

Bazadanych.sav

Download PDF

Reviewers agreed at journal
05 Sep, 2024
Reviews received at journal
01 Sep, 2024
Reviewers agreed at journal
29 Aug, 2024
Reviews received at journal
25 Aug, 2024
Reviewers agreed at journal
12 Aug, 2024
Reviewers agreed at journal
05 Aug, 2024
Reviewers invited by journal
30 Jul, 2024
Editor assigned by journal
30 Jul, 2024
Editor invited by journal
16 Jul, 2024
Submission checks completed at journal
12 Jul, 2024
First submitted to journal
09 Jul, 2024

You are reading this latest preprint version

Fear of Childbirth during Pregnancy and Birth Planning

Status:

Version 1

Abstract

INTRODUCTION

MATERIAL AND METHODS

RESULTS

Study Group Profile

Assessment of Somatic Condition

Experience from Previous Birth

Experience from the Course of Pregnancy and Birth Planning

Assessment of Mental Health Status

Stress Coping Strategies and Childbirth Education Classes Attendance

DISCUSSION

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1