Psycho-Social Predictors of Childbirth Fear in Pregnant Women : An Australian Study

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


Introduction
Giving birth for most women is a normal, healthy life event.However not all women believe they are capable of experiencing or achieving normal birth, and of having a positive birth experience.There is emerging evidence that childbirth fear may contribute to a longer labour, increased use of pain medication and emergency caesarean section (CS) [1]- [4].In addition to emergency CS, childbirth fear has been linked to request for elective CS which consequently contributes to overall increases in CS rates [5]- [11].High levels of childbirth fear in pregnancy are thought to influence women's decisions about birth mode.Previously Saisto et al. [12] identified that in Sweden and the United Kingdom, between 7% and 22% of requests for CS were due to childbirth fear.
Women's emotional health in pregnancy, particularly a history of anxiety and/or depression, has also been linked to childbirth fear [13]- [15].Women with antenatal childbirth fear and depression have been found to be at increased risk of postnatal depression and post-traumatic stress following birth [16].Recently Raisanen et al. [17] explored perinatal risks for developing postnatal depression in more than 500,000 Finnish women.Although a history of depression was highly related to postnatal depression, these authors also reported that women with childbirth fear and no history of depression were almost three times more likely to develop postnatal depression [17].
Previous work by our team identified that in a large sample of Australian pregnant women (n = 1410), around 25% of women had high childbirth fear [18].Personal variables such as age, education and income were not found to be associated with fear.However in line with the findings of others, parity and previous mode of birth (instrumental or caesarean section) were significantly associated with childbirth fear [4] [7] [18]- [21].
In Scandinavian countries, where the majority of childbirth fear research originated, antenatal care for fearful women has been primarily focused on improving women's emotional preparation to minimise requests for CS [8] [22].Although there is growing evidence that childbirth fear plays a part in the decisions that pregnant women make about mode of birth, there is scant work of this nature within the Australian context.Unlike personal demographic characteristics, many psycho-social factors are potentially modifiable and important to understand if we wish to reduce women's childbirth fear and increase their confidence for normal birth.
The aim of this current paper was to: 1) Identify pyscho-social factors associated with childbirth fear and possible antenatal predictors of childbirth fear; and 2) Determine differences in predictors for childbirth fear by women's parity.

Sample and Data Collection
2311 women between 12 and 24 weeks of pregnancy were approached in the antenatal clinics of three hospitals in south-east Queensland, Australia.The sample is drawn from participants (n = 1410) who consented to participate in the BELIEF study [23].Women were between 12 and 24 weeks pregnant, of any parity and any obstetric risk.Participants completed a questionnaire seeking demographic and obstetric details as well as levels of childbirth fear as measured by the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) form A. Inclusion and exclusion criteria, sample characteristics and data collection procedures have been reported elsewhere [18] [23].Women were asked questions pertaining to their previous mental health and preferred mode of birth.Other psycho-social variables were collected using validated tools including: 1) the Edinburgh Postnatal Depression Scale (EPDS) [24]; 2) the Decisional Conflict Scale (DCS) [25]; 3) two questions from the EuroQol (EQ-5D) [26] [27] were administered to assess pain/discomfort and anxiety/depression; and 4) several questions from Drummond and Rickwood's [28] Childbirth Knowledge Questionnaire (CKQ) and their Social Support/ Persuasions Scale (SSPS) were included to assess knowledge; and partner/general social support (see Box 1 for more detail on each measure).Recruitment occurred between April 2012 and June 2013.Ethical approval was obtained from the university and the three participating health services.

Data Analysis
Descriptive statistics were conducted on all variables and reported previously [18].Total scores for all standardised measures were calculated.The reliability of each scale used in the study was calculated.Cronbach's alpha values for the WDEQ were 0.94, EPDS 0.86, and DCS 0.97.Global scores were calculated for social support (minimum 0 and maximum 20) and childbirth knowledge (minimum 0 and maximum 18).Analyses were conducted for the whole sample and then by parity against the psycho-social variables hypothesised to impact high childbirth fear levels.Tests for parametric data were: independent T-test, Pearson's product-moment correlation coefficient and ANOVA; and for non-parametric data tests were: chi square, Spearmann's Rank Order Correlation, Kruskal-Wallis and Mann-Whitney U. Multivariate analysis was conducted to Box 1. Validated measures used in the study.

W-DEQ
The W-DEQ measures fear of childbirth by asking participants to rate their depth of feeling against 33 expectations and experiences before birth (version A) and after birth (version B) [51].Questions are presented in positive and negative formats on a six point Likert scale from 0 -5 requiring reverse scoring of positively formulated questions.A score equal to or lower than 37 is considered low fear, a score between 38 and 65 equates to moderate fear and a score equal to or higher than 66 represents a high level of fear [20].

EPDS
The EPDS is widely used in perinatal research and useful in screening for antenatal and postnatal depression [24] [52].The scale is a simple self-report questionnaire with 10 items.Women were asked to select one of four possible responses to each question.Each item is scored from 0 -3 and summed to produce a total score.The range of scores is from 0 -30 with higher scores indicating more negative feelings.The EPDS has been endorsed as a screening tool in the antenatal and postnatal Australian maternity population [53].EPDS scores of >12 in the antenatal or postnatal period have been recommended as an indicator of probable depression but not diagnostic of depression [53].

DCS
The DCS is a validated psychometric 16 item scale, which investigates concepts that can compromise or facilitate effective decision making (O'Connor, 2010).A score of 25 or lower (out of a possible score of 100) on the Decisional Conflict Scale (DCS) indicates an ability to make decisions (O'Connor, 2010).Scores ≥ 37.5 are associated with decision delay or feeling unsure about implementing decisions.Participants identify on a 5 point Likert scale of 1 = strongly disagree to 5 = strongly agree their certainty or uncertainty about decisions when there are tradeoffs of outcomes in a health related decision.The DCS has relevance to this study because determining a mode of birth for women who have fear of childbirth or who have had a previous CS can create uncertainty where the "individual feels uninformed about the alternatives, risks and benefits; is unclear about their personal values; or feels unsupported in making a choice or feels pressured to choose a course of action" [25].

EuroQol (EQ-5D)
EQ-5D developed by the international EuroQol Group [26] [27] is a 6-item self-report measure of health across the 5 dimensions of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression [54].The scale has been validated in healthy and unwell persons and can be used as a stand-alone measure or in conjunction with other psychometric instruments.To gain a baseline of women's health status on the day of entering the study one question pertaining to experiencing moderate or extreme pain and another on experiencing anxiety/depression were used from this scale.

CKQ
Childbirth Knowledge Questionnaire is a list of 9-items that each assess knowledge of behavioural techniques which may assist during the labour and birth process, attendance at antenatal classes, vicarious experiences relating to viewing and reading about childbirth and perceived knowledge about childbirth.Although Drummond and Rickwood [28] reported fair internal consistency (Cronbach's alpha = 0.68) analysis for the current study indicated that the items were not related and did not form a scale with psychometric properties.Furthermore, different response options were used for different items preventing the calculation of a reliability coefficient.Therefore a global score was calculated using 0 = No, 1 = Yes for dichotomised questions and for five item responses 0 = None to 4 = A lot or extremely; was assigned for a total possible score of 18.A question pertaining to behavioural techniques was not included.SSPS SSPS is a brief 5-item scale validated for Australian childbearing women [28].The measure includes items that examine verbal support received from a partner and/or significant others specific to the woman's current pregnancy and upcoming birth.The tool uses a 5-point Likert scale ranging from "never" or "none" to "very often" or "a lot" with higher scores indicating the woman has more social support.Internal consistency was reported using Cronbach's alpha and found to be 0.61 which is low [28].Analysis for the current study indicated that the items were not related and did not form a scale with psychometric properties.A global score was calculated using 0 = None or never to 4 = A lot or very often, for a total possible score of 20.
determine predictors of fear.

Birth Preference
The majority of participants indicated they would prefer a vaginal birth (n = 1220, 86.5%) with around twelve percent (n = 168, 11.9%) indicating a preference for a caesarean delivery.Twenty-two women (1.6%) indicated they were unsure or declined to respond.Of women indicating a preference for CS most were already mothers (multiparous: n = 131, 78%; nulliparous: n = 37, 22%).Around eight out of every ten multiparous women preferring caesarean section in the current pregnancy had a history of CS in their last birth (n = 103, 78%).Refer Table 1.

Previous Mental Health Condition
A mental health condition prior to pregnancy was acknowledged by 26% (n = 366) of women (refer to Table 1).Of these women, the most frequent mental health condition experienced was depression (n = 145, 10.3%) followed by anxiety (n = 62, 4.4%) and PTSD (n = 8, 0.6%).Around ten percent of women experienced a combination of conditions (n = 154, 10.9%), commonly depression and anxiety (n = 117, 75.9%).Of all women preferring CS around one-third reported suffering a mental health condition (n = 62, 37%).

Anxiety and Discomfort
Women completed two EQ5D questions [29] (describing anxiety/depression today and pain/discomfort today) to assess their wellbeing at baseline.Around one-fifth of women (n = 254, 18%) indicated they were experiencing moderate or extreme levels of anxiety or depression, and one-third (n = 512, 36.2%) reported moderate or extreme levels of pain.These symptoms occurred at similar frequency for nulliparous and multiparous women (Table 1).

Social Support and Childbirth Knowledge
Support from the father of the baby was acknowledged by 94.3% (n = 1329) of women.Three-quarters of women (n = 1062, 75.4%) reported having the same level or more detailed childbirth knowledge compared to other women.When comparing knowledge by parity, nulliparous women indicated less knowledge than multiparous women (n = 291, 47.8% vs. n = 48, 6%) (refer Table 1).

Decisional Conflict
A score of 25 or lower (out of a possible score of 100) on the Decisional Conflict Scale (DCS) indicates an ability to make decisions [25].Scores of ≥37.5 are associated with decision delay or feeling unsure about implementing decisions.The DCS scores of pregnant women indicated some difficulty in implementing decisions, and this was most specific to nulliparous women (Mean = 37.7, SD = 21.5, range = 0 to 100 vs. multiparous: mean = 23.7,SD = 22.3, range = 0 to 100).

Factors Associated with Childbirth Fear
Psycho-social variables of having a mental health history, feeling anxious or depressed, lacking partner support, experiencing moderate to severe pain in second trimester, desiring a CS for this birth, and low childbirth knowledge were statistically associated with higher childbirth fear scores (p < 0.001).Spearman's product-moment correlation coefficient revealed significant relationships between childbirth fear and decisional conflict (DCS) (p < 0.001), and depressive symptom scores (EPDS) (p < 0.001) both with moderate effect [30].See Table 2.
When analysed for differences by parity, psycho-social characteristics remained significantly associated with high levels of childbirth fear in women having a first and subsequent baby but with nulliparous women consistently maintaining higher fear levels to multiparous women.See Table 3.

Predictors of Childbirth Fear
Following the identification of statistically significant associations, standard multiple regression was used to  Effect size for Pearson and Spearman correlation moderate = ++ based on Cohen [30].
assess if EPDS, DCS, global scores for social support and knowledge and parity predicted levels of childbirth fear.The predictive model explained 32.4% of the variance in childbirth fear for nulliparous women and 29.4% in multiparous women.A comparison of Beta values indicated that depressive symptoms (EPDS) (beta = 0.360, p < 0.001) contributed most to childbirth fear in both nulliparous and multiparous women than DCS (beta = 0.201, p < 0.001), social support (beta = −0.149,p < 0.001) childbirth knowledge (beta = −0.133,p < 0.001) and parity (beta = −0.122,p < 0.001) (refer Table 4).

Discussion
A range of psychosocial variables contributed to childbirth fear.Possible depression, decisional conflict, lower levels of childbirth knowledge and lack of social support were predictors for childbirth fear in women.A significant strength of this work is the large representative nature of the sample that was inclusive of parity and obstetric risk (for example multiple pregnancy).However limitations such as recruiting women from the public sector only, and excluding women requiring an interpreter must be taken into consideration when interpreting the results.[28]; Significance * = 0.001; ** < 0.0005.
Our finding that women suffering anxiety or depression were more fearful is consistent with the work of others [9] [13] [31] [32].While anxiety is reportedly more common than depression and higher in the first and third trimesters of pregnancy [33]- [35], depression alone has been associated with risk for childbirth fear [15].In line with previous research, we also found depression symptoms (as measured by the EPDS) were a significant predictor for childbirth fear.Likewise Danish and Norwegian researchers found that the presence of anxiety and/or depression increased the risk for childbirth fear.However in their large sample size studies (n = 30,480 and n = 1642) the majority of fearful women were neither anxious nor depressed [14] [15].Symptoms of depression may contribute to women having a negative view of their personal capabilities, and of seeing the world as a safe and predictable place.These views may manifest in feelings of fear and uncertainty about childbirth.
A surprising result was the high-level of pain and/or discomfort reported by women.While minor discomforts are common across pregnancy [36] [37], around 36% of all women (39% in nulliparous) in the current study reported experiencing moderate or extreme levels of pain during pregnancy.The experience of moderate or extreme pain and/or discomfort was associated with childbirth fear.This finding is consistent with previous research that reported women with childbirth fear complained more often of physical ailments; and experienced more severe pain in third trimester as determined by a cold pressor test [31] [38].More recently Nordeng et al., [39] sought to determine the level of medication use in women with childbirth fear but did not find a relationship.While there is limited research on fear levels and antenatal discomfort; there is a link between antenatal fatigue and childbirth fear [19].Somatic anxiety and muscle tension have also been associated with fear levels [40].Arguably significant discomfort may be linked to fatigue levels and/or lower levels of confidence contributing to anxiety, tension and stress, and warrants further investigation.
While the majority of women in our study reported feeling well supported by their partners those who reported low support were more fearful.W-DEQ scores were on average 20 points higher in women who did not have partner support regardless of parity.These findings are consistent with previous research [9] [31]; and highlight the importance of maternity health care professionals exploring pregnant women's level of partner support.In contrast, Haines et al. [41] found no difference in levels of fear for women with or without partner support in a rural community.While fear measures varied across studies it may be that rural townships offer a greater sense of community that compensates for diminished direct partner support.
Again in line with findings of others, a lack of general social support was found to predict childbirth fear [14].Social support is a buffer to stressful situations [42] and without emotional and social support women have a greater likelihood of adverse pregnancy outcomes including preterm birth and perinatal depression [43] [44].Additionally, depression was found to be a risk factor for fear in this study.Women reporting childbirth fear may experience a vicious cycle whereby lack of social support contributes to depressive symptoms, and these symptoms diminish their ability to source and maintain social support.
A high level of decisional conflict, especially in first time mothers was common and associated with childbirth fear.A link between fear and decision-making has not been made previously.Indecision may be part of the same vicious cycle of events described above.While measuring decisional conflict has not been commonly undertaken, our findings are consistent with another study comparing Australian and Swedish women's birth attitudes and beliefs [45].In that study one-third of women in both countries were unable to determine their preference around birth options, with Australian women more uncertain than Swedish women [45].Despite the majority of women preferring normal birth, women with childbirth fear and depression may acquiesce to suggestions for a caesarean delivery.While higher decisional conflict in nulliparous women may be compounded by the unknown experience of birth, decisional conflict also contributed to childbirth fear in multiparous women, possibly due to conflict of having experienced a previous difficult birth.
Women's knowledge and/or cultural understanding of childbirth is also likely to play a significant role in how women approach birth.In our study multiparous women had higher levels of birth knowledge compared to nulliparous women, which is consistent with the work of others [28] [46].Women who felt less informed had a higher propensity for childbirth fear.It could be that lack of knowledge contributed to a perceived lack of control and fear.Without information, women are disadvantaged in their decision-making and birth planning.Certainly there is evidence that where women are involved in decisions and birth planning they feel more in control [47] [48].The identification of predictive factors for childbirth fear indicates the importance of assessing women and developing support strategies to ameliorate childbirth fear.Improving social support may reduce depressive symptoms perceptions of pain/discomfort and decisional conflict.Identifying effective and acceptable psychosocial interventions for pregnant women is critical to short and long-term maternal and infant health.Strategies are required to improve women's feelings and expectations of birth.These need to include developing women's knowledge to assist confidence with childbirth decisions, ensuring mechanisms are in place to monitor and treat anxiety and depression, and offering avenues for women during pregnancy to build social supports.Currently a randomised controlled trial is underway to test the efficacy of a midwife-led psycho-education intervention to address these issues with fearful pregnant women [23].
Support for this approach is evident in the research of those working with vulnerable and disadvantaged women whereby women receiving antenatal group care or continuity of midwifery care within social models have improved emotional health as well as birth outcomes [44] [49] [50].

Conclusion
Pregnant women with higher levels of childbirth fear report worse emotional, psychological and physical health.Psychosocial factors undoubtedly play a large part in how women having a first or subsequent baby feel about their upcoming birth.The results of this study support the recommendation that competent assessment of women with childbirth fear should occur to enable supportive strategies to be put in place, and that maternity providers should be skilled in listening and validating each woman's individual needs to alleviate women's negative feelings.

Table 2 .
Comparison of childbirth fear by psychosocial factors.

Table 3 .
Psycho-social associations to childbirth fear by parity.