Hows Does the Baby's Body Adjust to the Stress of the the Birth Process?
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Establishing a valid construct of fear of childbirth: findings from in-depth interviews with women and midwives
BMC Pregnancy and Childbirth book nineteen, Article number:96 (2019) Cite this article
Abstract
Groundwork
Fearfulness of childbirth (FOC) can have a negative impact on a woman'due south psychological wellbeing during pregnancy and her feel of birth. Information technology has also been associated with adverse obstetric outcomes and postpartum mental wellness difficulties. However the FOC construct is itself poorly defined. This study aimed to systematically identify the central elements of FOC as reported past women themselves.
Methods
Semi-structured interviews with pregnant women (n = 10) who reported to exist fearful of childbirth and telephone interviews with consultant midwives (n = xiii) who regularly work with women who are fearful of childbirth were conducted. Interviews were analysed using thematic analysis for each group independently to provide two sources of information. Findings were reviewed in conjunction with a third source, a recently published meta-synthesis of existing literature of women's own accounts of FOC. The primal elements of FOC were determined via presence in two out of the three sources at least one of which was from women themselves, i.due east. the reports of the women interviewed or the meta-synthesis.
Results
Seven themes were identified by the women and the consultant midwives: Fear of not knowing and not being able to plan for the unpredictable, Fearfulness of impairment or stress to the infant, Fright of inability to cope with the pain, Fear of harm to cocky in labour and postnatally, Fear of being 'done to', Fear of non having a vocalisation in decision making and Fear of being abased and lone. Ane further theme was generated by the women and supported by the reports included the meta-synthesis: Fearfulness almost my body'southward power to requite birth. Two further themes were generated by the consultant midwives and were nowadays also in the meta-synthesis: Fear of internal loss of control and Terrified of birth and non knowing why.
Conclusions
Ten key elements in women'due south FOC were identified. These tin can now be used to inform evolution of measurement tools with verified content validity to identify women experiencing FOC, to support timely access to support during pregnancy.
Peer Review reports
Background
Expectations formed about childbirth before or during pregnancy are fundamental determinants for women'due south experience of and behaviour earlier and during childbirth [ane]. Some women feel loftier levels of fright specific to giving nascence, and at its well-nigh severe fear of childbirth has been likened to a phobic response ('tokophobia') [1, 2].
Although some concerns relating to how a forthcoming birth may be experienced can be considered normal for many women, and may in some instances be potentially adaptive, severe fears of childbirth (or tokophobia) involving extreme fear, worry or business organization specific to giving birth [1] is likely to be more than problematic. To date, an absence of a clear definition for fear of childbirth and identification of levels that may constitute a phobic response has led to meaning heterogeneity in estimations of prevalence [ii].
Fearfulness of childbirth holds implications for women's experiences of pregnancy and nascency [3, 4]. Elevated fear during pregnancy has been associated with the progression of nascency (longer birth duration), an increased likelihood of intervention including augmentation of labour and emergency caesarean department [v,6,7,8] and an increased likelihood of elective caesarean section [9,10,11,12]. However studies exploring relationships betwixt fear of childbirth and adverse birth outcomes are inconsistent [7, xiii] and further examination is required.
Elevated anxiety and fear during pregnancy holds important implications for both maternal postpartum wellbeing and child evolution [fourteen, 15]. Although there are parallels between generalised feet and fearfulness of childbirth, studies accept shown that the two are not synonymous and can be considered separate constructs [16]. Furthermore, assessment of specific fear of childbirth has been identified as a superior predictor of both maternal and infant outcome over generalised anxiety lonely [16].
Despite international recognition well-nigh the bear upon and implications of FOC, the construct is poorly defined and current methods of identifying fright during pregnancy are varied [two, 17, 18]. In the United Kingdom, present recommendations include identifying depression and full general anxiety during pregnancy [19]. There is currently no routine pathway to ask specifically about women'southward fears of childbirth in the United Kingdom and provision of support varies [twenty, 21]. Furthermore, the dominance of tools adult in Scandinavian populations [17] has led to frequent use of measurement tools that concur uncertain utility for other populations where the focus of fear may vary [22, 23] or where translation into English renders the interpretation of items ambiguous [23, 24].
Reliable and valid identification of high levels of fear early in pregnancy could enable interventions to support and manage these concerns to reduce distress and fear of childbirth. However, in order to ask more specifically about FOC, it is important that a clear, comprehensive and culturally appropriate definition for fear of childbirth is developed. In addition to this, optimal timing of cess for FOC needs to be informed by the views of women and midwives.
Aim
To systematically identify the key elements that constitute the fear of childbirth construct. In improver, to identify women's and midwives' perspectives on optimal or preferred timing for asking about fears during pregnancy.
Methods
Blueprint
The study used a qualitative research design with semi-structured interviews. The interviews were conducted in two stages.
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Stage ane consisted of semi-structured interviews with women who reported to be fearful of childbirth.
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Stage two consisted of semi-structured telephone interviews with consultant midwives who regularly support women who are fearful of childbirth.
Setting
Interviews with women were either conducted at the Liverpool Women's Infirmary NHS Foundation Trust (LWHFT) (n = 1), or in the adult female'south home (n = 9), the choice of venue was guided by the women's preference to ensure maximum comfort for the adult female. All consultant midwife interviews were conducted by telephone (north = thirteen).
Upstanding approving
Ethical approval was sought and obtained from the University of Liverpool (15/NW/0922) and the written report was sponsored by University of Liverpool (UoL00177).
Participants
Phase one
Pregnant women under the care of the consultant midwife for reasons relating to fear of childbirth, who were aged over sixteen years and fluent in spoken English were eligible to participate. Women who had a history of stillbirth or intrauterine decease, an ongoing serious maternal medical condition, where there was a medical concern for the baby in their electric current pregnancy, or if they were under the care of the fetal medicine unit, the perinatal mental wellness squad or the enhanced midwifery team were non eligible to participate.
The timing of recruitment was pragmatic; women who reported to be experiencing a fear of childbirth as part of standard care were referred by their midwives to the consultant midwife at LWHFT. Their fearfulness of childbirth was then assessed past the consultant midwife during a routine clinical engagement. The research interviews were bundled, at the woman's earliest convenience, after the consultant midwife had gained consent. All women were interviewed in the tertiary trimester. Demographic details for the participants is presented in Table 1.
Phase two
All midwives (north = 13) had worked within a consultant midwife role for at least a year (range 1–xviii years) and regularly supported women with a fearfulness of childbirth. Their more full general experience of midwifery ranged up to thirty years.
Recruitment continued until the data reached saturation: for women (northward = ten) and for consultant midwives (n = 13).
Materials (interview guides)
For the interviews with women, open questions enquired generally about women's fears for childbirth, the main elements of their fear and what impact their fears had on their feelings about their pregnancy and their daily life. Participants were also asked about the blazon of questioning that would enable them to disclose a fearfulness of childbirth during antenatal intendance and what barriers they might perceive when trying to share their fears. The interviews with midwives focused on professional person perspectives on the key elements of the fears that women study and the impacts of these for women. Interviews also incorporated additional questions on optimal methods for encouraging women to disembalm their fears, timing of screening women in antenatal care and perceived barriers to implementing a screening tool. Interviews with both groups lasted up to 60 min. The interview topic guides for women and midwives are provided as Additional files 1 and 2 respectively.
Process
Phase ane
Potential participants were identified every bit eligible and given information about the study from the consultant midwife and asked whether they would similar to receive farther information from the researcher. Details of the study were also presented on the LWHFT website and LWHFT social media websites (Twitter, Facebook) to ensure that all pregnant women were given the opportunity to read well-nigh the study and were able to contact the researcher directly to inquire virtually participation. The researcher so contacted women to provide further information near the written report. On receipt of consent, the researcher arranged a suitable time to conduct the interview.
Stage two
Recruitment took place via snowball sampling and the UK Consultant Midwife network. Midwives interested in hearing more about participating in an interview were asked to contact the researcher for further discussion.
Assay
Interviews were audio recorded and transcribed ad verbatim. Each interview was analysed using thematic assay [25] to identify cardinal concepts associated with fear of childbirth. The almost simplistic form of thematic analysis was used as we solely wished to place the range of FOC. Each transcript was re-read and coded line past line to identify and extract the descriptive information. These descriptions were tentatively grouped into initial themes by KB which were then discussed with the core team who reviewed the labels and testify throughout the process relabelling and refining final themes equally advisable. Analysis and synthesis across individuals was completed by KB sequentially for primiparous women followed by multiparous women and subsequently consultant midwives. To increment rigor, two interviews were double coded (KB & PS). All iterations of themes were verified past all 4 authors. The researcher (KB) was blind to the meta-synthesis utilised in the last integration every bit outlined below prior to the completion of interview analyses.
The themes derived from Stages One and Two were and so reviewed by the research team (KB KS GH and PS) alongside those generated from a recently conducted meta-synthesis [26], which examined the content and moderators of women's fears for giving birth as reported by women in the wider literature. Reviewing the themes generated from the present enquiry with those identified as reported by women in the wider qualitative literature enabled the integration of findings representing key elements of fear of childbirth.
In order to identify fundamental elements of the construct, an a priori decision was implemented whereby last themes included only those elements supported past ii of the 3 sources (women's interviews, consultant midwife interviews or meta-synthesis). Once again, to ensure priorisation of women's voices, at to the lowest degree 1 of the sources had to be grounded in women'southward accounts of their fear (the women's interviews or the meta-synthesis, which had just included papers derived from primary evidence from women themselves).
Results
Pace one: themes generated from women
Consideration of findings from primiparous (P) and women and multiparous (M) women
As in that location was a possibility that fears might differ betwixt primiparous and multiparous women these were initially analysed separately. Interviews with primiparous (P) women (n = 3) generated viii initial themes (areas of fear). Our purpose was to place all potential areas at this point. Of these, all 3 women shared 6 intial themes of fear of childbirth: 1. Fear of inability to cope with the pain, ii. Fearfulness of my body'due south inability to requite birth, 3. Fearfulness of harm or stress to the baby, iv. Fear of the unpredictability of childbirth, five. Fright of my lack of ability to plan and half-dozen. Fear of damage to self. Ii of the primiparous women also reported 7. Fear of long-term implications of damage from labour and childbirth. I woman was fearful of viii. Not being 'heard' during labour or having an ability to influence what happens.
All 8 initial themes generated from primiparous women were reflected in the analysis of information from multiparous (Grand) women with the addition of 3 further initial themes; 9. Fright of being abased/alone in labour and childbirth, ten. Fear of length of labour and 11. Fearfulness of intervention (including any processes that made them feel 'done to'). Through discussion with the full team it was clear that 'Fear of length of labour' reflected the same concerns as 'Fright of disability to cope with the pain', as often the focus was fear of a long or a short labour that is either associated with long and laborious labouring procedure or a fast and acutely painful labour. Therefore, information technology was agreed that only 'Fear of existence abandoned/alone in labour and childbirth' and 'Fear of intervention (including any processes that made them feel 'done to')' were additional initial themes.
As all initial themes identified by primiparous women were later confirmed by multiparous women the team agreed information technology was appropriate to fully integrate the analysis whilst ensuring all central elements from both groups continued to be represented.
All data was therefore reanalysed using the total data set and a set of 8 terminal themes from all the women's interviews were identified. Whilst these clearly reverberate much of the original analysis points of conceptual overlap enabled a reduction in number from the original 11 initial themes to 8 final themes. Final themes and their derivation were as follows: 1. Fear of not knowing and not being able to programme for the unpredictable (from related to previous categories of Fear of the unpredictability of childbirth and Fear of my lack of ability to program), 2. Fearfulness of harm or stress to the babe 3. Fearfulness of inability to cope with the hurting 4. Fear of my torso's ability to give nascence (related to previous category Fear of my body'south inability to give birth) five. Fear of harm to self in labour and postnatally (related to previous categories Fear of harm to self and Fear of long-term implications of damage from labour and childbirth) 6. Fright of beingness 'done to' (related to previous category Fear of intervention including any processes that made them feel 'done to') 7. Fright of not being heard (related to Not beingness 'heard' during labour or having an ability to influence what happens) and 8. Fear of beingness abandoned and lone (related to previous category Fear of beingness abased/alone in labour and childbirth). The process of theme generation from initial themes to concluding themes is presented for women in Fig. 1.
Representation of thematic process for multiparous and parous women. Notation. *fears solely identified by multiparous women. All other fears identified by multiparous and primiparous women
Step two: themes generated from midwives (C)
The starting time iteration of assay from the consultant midwives (C) interviews generated xiii initial themes: 1. Control (which incorporated a lack of control over the situation and a fear of an internal loss of control), 2. Fear of not receiving the care they would similar (which incorporated not existence listened to, not being involved in decision making and a general lack of trust in healthcare providers), 3. Fearfulness of the unknown/unpredictability, 4. Fear of pain, five. Fear of the length of labour (which included both long and quick labours), 6. Fear for the safe of the baby (from harm of the babe through to death of the infant), 7. Indeterminate fear (which included not being sure of what they were afraid of and not establishing the cause of the fear), 8. Fear of the same matter happening once more, 9. Fear of consecration, 10. Fear of intervention, 11.Concrete damage from the birth (including damage to the vagina, damage to the perineum, tearing or stitches), 12. Fear of decease and xiii. Fright of things going wrong.
Through team word and further iterations of the data these initial themes were streamlined into 9 terminal themes: 1. Fear of the birthing process beingness uncertain and unpredictable, (which amalgamated initial themes 1. Fear of a lack of command over the situation and initial theme 3. Fear of the unknown/unpredictablity, 2. Fear for potential damage or expiry of the baby (which reflected initial theme half dozen. Fear for the safety of the babe in the first iteration), 3, Fear of intensity of pain (which incorporated both initial theme4 Fear of inability to cope with the pain and initial theme 5 Length of labour equally i main theme, every bit the themes were conceptually linked) 4. Fright of harm to self (this theme expanded to contain initial theme 13 when things going wrong in labour, and initial themes eleven and 12 with the woman being hurt, injured or dying, as well equally post nativity impairment), 5. Fear of procedures being 'washed to' them (this theme amalgamated initial theme 9 Fear of induction and initial theme ten fear of intervention in general), 6. Fear of not beingness listened to and not having things explained (this theme was streamlined from initial theme non receiving the care they would like and a fearfulness of their loss of influence over determination making processes and choices), 7, Fear of beingness abased/alone (This theme was created from the previous initial theme 8. Of the same thing happening over again, equally many women had felt abandoned and alone during their previous labour and birth, and initial theme 2 non receiving the care that they would like), 8. Fright of internal loss of command (this theme was generated from initial theme1 Command but was streamlined to focus more on the internal loss of control rather than loss of control of the state of affairs), nine. Terrified of birth and not knowing why (this theme was initial theme 7 in the first iteration and remained the same). The process of theme generation from initial themes to concluding themes is presented in Fig. two.
Representation of thematic process for consultant midwives. Note. Initial groupings of categories are indicated via internal dashed boxes
Cardinal elements for fear of childbirth
To ensure appropriate content validity, each theme had to reflect women's ain voices and exist confirmed by one of the other sources. Therefore, as women's voices were represented in both the interviews with women and the meta-synthesis [one], each key element is supported past one of these sources plus an boosted source of bear witness.
Therefore, overall, 10 themes which could be considered primal elements for fearfulness of childbirth were identified (Table 2). Seven themes were identified from the women and supported by the consultant midwives: 1 was generated from the women and supported by the women'south reports in the meta-synthesis and two boosted themes were generated past the meta-synthesis and were supported by the consultant midwives. This derivation is shown in Table 3 which shows all themes from all three sources. Each key element is in greater detail below.
Fright of not knowing and not being able to plan for the unpredictable
Women reported that they were fearful of the unpredictable nature of birth and were concerned that they are unable to plan for this unpredictable event. For primiparous women, this presented in the form of a lack of cognition or feel of how to manage the event, for multiparous women it was more an understanding of how unpredictable the birthing procedure can exist, given their previous experience. This was supported by the consultant midwives under the theme of 'Fear of the birthing process being uncertain and unpredictable'. Many of the midwives speculated about whether the fright is generated because women command so many aspects of their solar day-to-twenty-four hours life only cannot command the birthing process.
For some, the opportunity to create a detailed birth plan abated this fear. Nonetheless, for many, the unpredictability of who would activity the birth plan or exist on duty that day didn't reduce (and in some cases increased) this sense of unpredictability.
'I am notwithstanding scared and I however don't like the thought of unpredictability in anything.
Predictability brings control.' (P19).
'I don't know how the births going to go or what's going to happen again, yous know you're not in control of it, it'southward just dead scary.' (M21).
'My view is that women have then much control over every aspect of their life, they discover information technology – childbirth a really difficult matter to practice. In terms of them not being able to predict what's going to happen, not, not feeling every bit if they've got control. It, It, it, it's hard to package into a life where you manage everything else so tightly'. (C3).
Fear of not having a vox in determination making
Women were fearful of not existence involved in conclusion making throughout the labour and birthing process. This was mainly identified by multiparous women, nevertheless one primiparous woman as well identified this as a fear. Despite being able to write a detailed nativity plan and talk over their hopes and fears about their nativity with the professionals beforehand, in that location was a fear that during the birthing process their requests would be missed. This theme was identified by the consultant midwives as 'Fear of not existence listened to and not having things explained - Loss of influence over decision making and choices' and they spoke of women (particularly multiparous women) reporting that they were not involved during their previous labour when decisions were being made.
'Simply when I spoke to the midwife and told her what *** (consultant midwife) had said, she said 'oh I think you lot should brand sure that that is in your birth plan and y'all go on saying it and keep maxim it and if they don't mind that yous exercise speak to somebody higher'. So even though *** (consultant midwife) had reassured me so I felt a bit… scared again.' (M8).
'Then the case that I take had actually are women who have wanted to remain upright and mobilising but they frequently come to me and say 'I wasn't able to movement around, I wasn't given a pick… I wanted to exercise X, Y and Z and yous wouldn't let me' (C18).
Fearfulness of impairment or stress to the baby
Women reported a fearfulness of the baby being injure in the process of labour and childbirth. For them, impairment to the infant ranged from the baby being distressed during the labour and delivery to the infant being physically harmed in the process. This was also identified by the consultant midwives 'Fear for potential harm or death of the baby'. The consultant midwives tended to written report a greater fearfulness of the concrete harm to the baby rather than distress to the baby and also reported a fear of the baby dying, which was non identified by the women in this report.
'I am scared for the babe. I don't want the infant to go through annihilation – from like getting pulled out past the forceps or the suction- the cup- or anything, I'd rather…effort and…avoid whatever I can for them.' (P1).
'And so I remember it is the fear of losing the baby as well when in labour or having a damaged baby'. (C10).
Fear of inability to cope with pain
Fear of pain non merely included women's power to manage the intensity of the pain but also their concern nigh whether they would receive the appropriate level of pain relief for them to cope. Fearfulness of hurting was also identified by the consultant midwives who noted that multiparous women ofttimes remember the pain from final time, only it is variable every bit to whether that then becomes the master focus of their fearfulness in the electric current pregnancy. They also reported that for some women their fear of pain is not specific to childbirth; more a wide fright of being unable to cope with pain in general.
'I am fearful – I am really scared of the pain' (P3).
'And a lot of it is around the hurting relief equally well, you lot shouldn't be expected to be in that amount of pain ever.' (M20).
'I hateful you do get the women that come in and go 'I can't, I can't cope with hurting, I'm an absolute wuss, I only want to accept an epidural and that's fine' (C11).
Body'southward ability to give nascence
This element was identified by the women and inside the meta-synthesis but not past consultant midwives. The women reported a fright of their trunk'due south physical capacity to birth the baby. Their fears included their own trunk size, their baby's size/positioning and their concrete forcefulness.
"I feel that my pelvis is really minor and I've got a narrow pelvis." (P iii).
"I'yard terrified in example the head merely – if anything goes incorrect – the head was to turn or I couldn't get her out." (M6).
Fright of harm to cocky in labour and postnatally
This element of fear captures the belief that something 'bad' volition happen in labour. The term 'harm' encapsulated a range of fears, from feeling generally unsafe during labour through to a fright of dying in labour and childbirth. This was reflected in the consultant midwives interviews besides nether the theme of 'Fearfulness of harm to self', and this theme oft referred to women being fearful of being physically damaged during nascence or dying.
"And I think nigh the day that I have to go in for the section and I look at my piffling boy and I'thou thinking am I actually non going to see him again, am I really non going to see him over again? (sobbing)." (M22).
"They just take been getting this drip, drip, drip effect of negativity and if the only thing is negative, that nascency is this horrible feel that is going to traumatise me and wreck my trunk and I could die…" (C7).
The fear of impairment to self, included a sub-theme of potential mail service-natal complications. Women and consultant midwives both reported that women fright that the labour and birth might lead to a boring and painful healing procedure, ane that creates irrevocable harm to the woman'due south body.
"My human relationship with my husband is of import to me and I worried that information technology would change later on birth" (P19).
"And like the last thing I desire is when I come up domicile, I tin't selection my little girl up and I tin't give her all the large cuddles and everything because I have got this big scar on my stomach." (M21).
"They're worried that their perineum and their ongoing sexual health volition be damaged" (C3).
Fearfulness of being 'done to'
This refers to a more general fearfulness of intervention of any sort, ranging from vaginal examinations to instrumental deliveries. Women referred to feeling like 'a piece of meat'. This theme is characterised past the words 'washed to' every bit this was often the phrase women used about these interventions, as if they were not a participant in the process. This theme reflects more than just a lack of communication, but a feeling of violation of their body during procedures. This was also reflected in consultant midwives reports of 'Fear of procedures beingness done to them'.
"I am absolutely petrified of needles. Petrified. And so I was like, do not allow me become that epidural whatever I say no matter how drastic I am don't let me get it." (M13).
'And then, having all of that intervention potentially, lots of examinations, lots of monitoring, drips, you lot know, not getting whatsoever sleep. When you cease up going down that sort of pathway of interventions, people finish upwards not being able to eat, not beingness every bit mobile and information technology is merely a horrible process.' (C16).
Fear of being abased/alone
This chemical element, for the women, was mainly around being physically left alone by staff when they did not wish to be and also a fear that their chosen nascency partner wouldn't be able to exist by their side when they needed them. This was as well identified by the consultant midwives as 'fear of beingness abandoned/alone' simply was more frequently referring to staff members (rather than nascence partners) when they felt they needed support. Within the meta-synthesis this element also included an aspect of existence psychologically solitary during labour and birth.
"(if has a caesarean-section) And so at least I know I won't be left in a room simply dealing with it" (M8).
"*** (husband) works in (city). So and I know that plainly with winter coming and the traffic is all bad, the M62 is horrendous and with my mum dying I've got no mum" (M20).
"…'I was left you know, but left with this baby and the midwife left the room' and and then nosotros are trying to you lot know, it is most getting the midwife to stay in the room and practice the computers and the notes in the room with the women, so the women have people at that place for back up" (C11).
Fear of internal loss of control
Although this was not identified by the women in this study, it was identified by the consultant midwives and also within the meta-synthesis. It refers to a feeling virtually an internal turbulence and loss of self-control, where the woman no longer feels she is able to manage herself, which tin can atomic number 82 to her battling internally throughout the labour and birth.
"They but don't like the thought of existence out of control and knowing that they are out of command." (C5).
Terrified of birth and not knowing why
Although this was non captured in interviews with the women in this study, this was reported past the consultant midwives and was also noted in the meta-synthesis. Information technology is an element which represents a more general feeling of fear without whatsoever agreement of the specific reasons for feeling fearful, and a lack of root cause for the fear of labour and childbirth.
"There's very rarely a root crusade that I find, even though I spend equally much time as the woman wants talking to them they are frequently unable to clear why this fear is - information technology's just there" (C3).
"But some people are genuinely frightened and there are lots of women that are frightened just for lots of… yous know, the unknown reasons" (C1).
Women'south views most when FOC should be assessed
During the women's interviews, the women were also asked their views nigh when the appropriate fourth dimension to complete an assessment for FOC would be or when whatsoever discussions around FOC should take identify and the overwhelming majority of women felt that questions should exist asked about fear as early on as possible to ensure appropriate back up can be put in place:
"And I think we should be asking women right at the beginning virtually their fears because I think when you lot notice out you are pregnant information technology is the affair you lot think about the most. Because obviously I knew I was meaning as soon every bit it had happened, then it's kind of yous starting time thinking about information technology, you outset thinking again what happened last time…so you do call back about it straight away yeah. Definitely need to talk to women about this" (M20).
"Something around someone saying 'well take you got any concerns most delivery' at a very, very early on stage might assistance. Because I think I was kind of, I think that at about vi weeks I was in tears with the community midwives talking about delivery. And so I was, right from the get become, I was thinking – and maybe I am unusual in that respect, I don't know. I don't know what other ladies have said but I kind of retrieve that even if – even if that was identified quite early on and y'all've got kind of those conversations with the consultant midwife much before I retrieve that might assistance". (M5).
"I call back equally early on as you can ask them open up questions to understand if in that location is any fears that you can deal with and book people in with the appropriate people and take time to exercise that and then. For me that'south the best." (M22).
"Not beingness able to hash out until you are thirty whatever weeks – it's too belatedly." (M13).
Midwives views about when FOC should be assessed
During the consultant midwife interviews, midwives were asked their views nearly when the advisable time to assess for FOC would exist. All midwives felt it should be completed before xx weeks and the majority felt it should be as early as possible (generally around booking time):
"So for me the sooner we can back up women, run into women to talk most it, the better information technology is considering we tin can commencement to manage those expectations. We can manage it in sizeable chunks that are led past the woman not me." (C9).
"Send that adult female to see someone early in the pregnancy considering the longer you lot dismiss it and ignore it the greater the worry and feet for that woman and the shorter the amount of time." (C15).
For those who suggested later than booking (i.e. 16 weeks or 20 weeks), it was often due to applied bug in terms of the corporeality of paperwork that already needs to be completed at booking. Those midwives suggested that a further demand on this already busy engagement might exist impractical.
"Possibly at 16 weeks. There is and so much going on at booking, there is and you know you lot can acknowledge fear and say 'this is something you know we will explore in more detail at your next date' possibly say 'have a call back, hither'south the list of questions' you lot know, do some sort of preparation for that chat, so y'all're acknowledging that this women is frightened of nascency in some mode. Yes simply I think peradventure xvi weeks is a good time to start." (C16).
Discussion
There is an emerging accent on the demand for a articulate, usable definition for the fear of childbirth construct [ii, 17] which has established validity. Findings from this qualitative investigation integrates accounts of women experiencing high levels of fear almost giving nativity, perspectives of consultant midwives experienced in supporting women experiencing fear of childbirth, and women's accounts of their fear every bit reported in the wider qualitative literature (from a recently completed meta-synthesis) [26] to establish ten primal elements underpinning and present within the fear of childbirth construct.
Parallels between the perspectives of both primiparous and multiparous women, consultant midwives, and findings reported in the wider qualitative literature emphasise the axis of the fundamental elements in the fear of childbirth construct. Fear of the unknown highlights the function of uncertainty and unpredictability in the birth process eliciting fright. Not feeling heard during the birthing process, fearing harm or stress to the baby, concerns over coping with pain, feeling 'washed to' or abandoned during the nascence were elements strongly endorsed by women and midwives as important elements of fear of childbirth. Several of these elements take also been identified as important for the identification of fear of childbirth post-obit a recent review of quantitative literature [23].
There were nevertheless differences identified between each of the sources used to develop the construct. It is interesting to annotation that fright of their body's capacity to requite birth was just reported in women's interviews and the meta-synthesis26, and non in the midwives' interviews; indicating the importance of this element inside the definition for FOC and any screening tool, equally it currently unlikely to be a question that is specifically asked by midwives.
The element of 'fear of internal loss of control' was only captured by the accounts of women reported in wider qualitative studies via the meta-synthesis and thus warrants further exploration. Within the meta-synthesis, women reported concerns over losing physical or emotional control during the nascence, and this leading to either not 'performing well' or non co-operating with staff [26]. Even so this was not an chemical element of fearfulness reported by women interviewed equally role of the present study, indicating that this aspect of women'due south fears requires further exploration.
The element of generic fear of the unknown was an interesting theme and raised some questions within the core team during the analysis procedure. Given that anxiety and fear is often coupled with a significant corporeality of avoidance [27], this might be more cogitating of the challenges of truly engaging these women in exploring their fears rather than an chemical element of fear itself; however, this requires farther exploration. For instance, previous qualitative investigations have identified that women experiencing loftier levels of FOC may attempt to avoid thoughts or talking well-nigh their fears [28, 29], and it is plausible to suggest that this may have resulted in the generic element for fear of the unknown. Findings also highlight perspectives of women and midwives regarding the optimal timing for asking nearly fear during pregnancy with both women and midwives report that early on identification is preferable. Supporting women to discuss fears as early as possible during pregnancy will enable timely admission to back up to help mitigate or alleviate concerns, and potentially prevent women experiencing loftier levels of fear of childbirth throughout their pregnancy. Further research is required to identify feasible and adequate methods of introducing strategies to identify FOC at an early on stage of antenatal care.
Strengths and limitations
A particular force of this study is that information technology reflects the voices of both primiparous and multiparous women and each chemical element remains as close to the women's linguistic communication and phraseology as possible (eastward.g. 'washed to'). This will enable women who are fearful to identify with these key elements in hereafter work and find them truly cogitating of their feelings about labour and childbirth. In that location was a high degree of consensus between the women and the consultant midwives' elements for fearfulness of childbirth, emphasising the utility of these elements for inclusion in a time to come screening tool. It is as well interesting to note the homogeneity in fears reported past primiparous and multiparous women, however it must be noted that the current sample included only iii primiparous women. The sample is self-selecting and given the nature of the interviews it is highly probable that the interviews did not capture the views of those women who are significant and also afraid to talk about their feelings. Nor does information technology capture those who are avoiding becoming significant because of their fear of childbirth.
All women were in their 3rd trimester when they were interviewed, given that women's fear of childbirth increment in the 3rd trimester [30], future studies might consider reviewing women's fear of childbirth in all 3 trimesters. Also, this written report only included 3 primiparous women, and although the themes generated were reflected in both groups, studies have suggested that the content of fears of childbirth might be different for primiparous and multiparous women [31], therefore this might warrant further exploration in future studies. However, themes were reviewed in parallel to those obtained from a meta-synthesis of women's accounts of their fears for giving nascency, where the views of both multiparous and primiparous women were included [26].
The function of partner relationship may be of relevance in relation to fears of childbirth too [32], and the marital status of the participants in this study were noted and reflected a typical blueprint in pregnant women with the majority existence married or cohabiting.
Relevance to clinical practice
Clear identification of women who are fearful of childbirth will let healthcare professionals to activate an early and constructive pathway of care for these women. Notwithstanding this requires appropriate measurement tools that must be derived from a clearly articulated and evidence based construct for fear of childbirth [17]. The current study combines data from three sources to identify fundamental elements of central to a construct of fear of childbirth every bit reported past women themselves. By defining the central elements of fear of childbirth, the evolution of relevant and culturally appropriate measurement tools with loftier content validity, or examination of existing tools, can exist facilitated. These key elements as well provide an insight into what should be included in packages of care to ensure effective and relevant back up for these women. The side by side phase of the piece of work is to assess women'due south agreement of items in existing tools and to map the emergent elements from this study across existing ways of assessing FOC.
Although development of a culturally appropriate definition of FOC for UK is necessary, there remains a demand to develop current understanding regarding the definition, identification and back up for women experiencing FOC on an international footing. Whilst there will be differences between populations regarding the focus and content of fears, it is plausible to suggest that there will also exist parallels; every bit evidenced by those elements identified in Sheen and Slade's26 meta-synthesis where reports of fears on an international footing were integrated. Findings from the present report may therefore contribute to understanding the key elements of FOC experienced by women regardless of cultural context.
Conclusions
This study identified 10 key elements present in women'south accounts of their fear of childbirth, supported by the accounts of midwives with feel of providing support in this context. In that location was a clear preference to implement methods of identifying fear of childbirth early in pregnancy. These findings tin be used to inform development of comprehensive and culturally appropriate methods of identifying fearfulness of childbirth during pregnancy, and besides hold implications for the shaping of supportive interventions aimed at reducing women's distress and fearfulness of childbirth prior to nativity.
Abbreviations
- FOC:
-
Fear of childbirth
- LWHFT:
-
Liverpool women'due south hospital NHS foundation trust
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Acknowledgements
The authors would similar to thank Maureen Treadwell (Birth Trauma Clan) and Jenny Butters for assist in the pattern and development of this project. The authors would also like to give thanks Rachel O'Keefe (research midwife) for her back up in recruitment.
Funding
This research was funded by Liverpool Clinical Commissioning Group.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
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Contributions
PS, KS, GH designed the study, GH and KB recruited participants, KB conducted and analysed the interviews, all authors were involved in refining the analysis, KB prepared the manuscript, all authors read and canonical the last manuscript.
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Ethics approval and consent to participate
Upstanding approval was sought and obtained from the University of Liverpool (15/NW/0922) and the study was sponsored by University of Liverpool (UoL00177). Informed written consent was obtained from all participants prior to interview..
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The authors declare that they have no competing interests.
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Additional file 1:
Topic guide for fear of childbirth semi-structured interview with women (DOCX 29 kb)
Additional file ii:
Topic guide for fear of childbirth semi-structured interview with consultant midwives (DOCX 18 kb)
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Slade, P., Balling, K., Sheen, One thousand. et al. Establishing a valid construct of fear of childbirth: findings from in-depth interviews with women and midwives. BMC Pregnancy Childbirth 19, 96 (2019). https://doi.org/10.1186/s12884-019-2241-7
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DOI : https://doi.org/x.1186/s12884-019-2241-seven
Keywords
- Antenatal anxiety
- Childbirth anxiety
- Fear of childbirth
- Qualitative tokophobia
Source: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2241-7
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