Scholarly article on topic 'Psychological perspectives on fear of childbirth'

Psychological perspectives on fear of childbirth Academic research paper on "Psychology"

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Journal of Anxiety Disorders
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{Anxiety / Fear / Avoidance / Childbirth / Pregnancy / "Literature review"}

Abstract of research paper on Psychology, author of scientific article — Elisabet Rondung, Johanna Thomtén, Örjan Sundin

Abstract The objective of this narrative review was to examine the literature on fear of childbirth from a psychological perspective, addressing the specificity of childbirth fear, the pathways of fear acquisition, and the physiological, cognitive and behavioral aspects of fear. Systematic procedures for literature search, inclusion and exclusion left 86 original research papers for analysis. Findings summarize the body of knowledge for each area of interest, as well as the number of studies addressing each theme. Overall, few studies adopt a clear-cut psychological perspective, leaving the psychological mechanisms of childbirth fear largely unexplored. Although methodological limitations make conclusions difficult, results give a hint of etiological diversity and possible psychological mechanisms commonly described as transdiagnostic features in anxiety. Systematic investigations of psychological mechanisms, longitudinal studies exploring possible vicious circles of fear, and studies comparing psychological characteristics within the group of women fearing childbirth are identified as research areas of high priority.

Academic research paper on topic "Psychological perspectives on fear of childbirth"

Anxiety Disorders

g 1 <" , ^ Contents lists available at ScienceDirect

V I I Journal of Anxiety Disorders



Psychological perspectives on fear of childbirth

Elisabet Rondung*, Johanna Thomten, Örjan Sundin

Department of Psychology, Mid Sweden University, 831 40 Östersund, Sweden


The objective of this narrative review was to examine the literature on fear of childbirth from a psychological perspective, addressing the specificity of childbirth fear, the pathways of fear acquisition, and the physiological, cognitive and behavioral aspects of fear. Systematic procedures for literature search, inclusion and exclusion left 86 original research papers for analysis. Findings summarize the body of knowledge for each area of interest, as well as the number of studies addressing each theme. Overall, few studies adopt a clear-cut psychological perspective, leaving the psychological mechanisms of childbirth fear largely unexplored. Although methodological limitations make conclusions difficult, results give a hint of etiological diversity and possible psychological mechanisms commonly described as transdiagnostic features in anxiety. Systematic investigations of psychological mechanisms, longitudinal studies exploring possible vicious circles of fear, and studies comparing psychological characteristics within the group of women fearing childbirth are identified as research areas of high priority.

© 2016 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND

license (


Article history:

Received 3 March 2016

Received in revised form 22 August 2016

Accepted 13 October 2016

Available online 18 October 2016



Avoidance Childbirth Pregnancy Literature review


1. Introduction.............................................................................................................................................81

2. Method..................................................................................................................................................81

3. Results...................................................................................................................................................82

3.1. Fear of childbirth: a specific syndrome?........................................................................................................82

3.2. Fear acquisition..................................................................................................................................82

3.2.1. Fear conditioning......................................................................................................................82

3.2.2. Vicarious experiences.................................................................................................................83

3.2.3. Transmission via information.........................................................................................................83

3.2.4. Primary and secondary fear of childbirth.............................................................................................83

3.2.5. A vicious cycle of fear..................................................................................................................84

3.3. Physiological aspects ............................................................................................................................ 84

3.4. Cognitive aspects................................................................................................................................84

3.4.1. Objects of fear.........................................................................................................................85

3.4.2. Self-efficacy and perceived stress coping ability......................................................................................85

3.4.3. Pain catastrophizing...................................................................................................................85

3.5. Behavioral aspects...............................................................................................................................85

4. Discussion...............................................................................................................................................87

Appendices 1-5 Supplementary data..................................................................................................................88

References .............................................................................................................................................. 88

* Corresponding author.

E-mail addresses: (E. Rondung), (J. Thomten), (Ö. Sundin).

0887-6185/© 2016 The Author(s). Published by Elsevier Ltd. This is an open access article underthe CC BY-NC-ND license ( 4.0/).

1. Introduction

Nearly 80% of pregnant women express worries and fears in relation to their pregnancy or upcoming childbirth (Melender, 2002a). For a great deal of these women the fears are strong enough to be clinically relevant. However, estimations of prevalence are equivocal, presumably due to the lack of clear-cut definitions and conceptualizations of the concept to be measured (Saisto & Halmesmaki, 2003).

A wide array of methods has been used to capture childbirth fear, including more or less validated instruments, single questions, and diagnostic codes. The most widely used measure of fear of childbirth, the Wijma Delivery Expectancy-Experience Questionnaire, W-DEQ (Wijma, Wijma, & Zar, 1998) is a 33 item 6 point Likert scale in which the items refer to cognitive and emotional expectations of the forthcoming childbirth (e.g. responding to the question, "How do you think you will feel in general during the labour and delivery"), with anchor words indicating opposite extremes of the expected experiences (e.g. "Extremely strong" vs. "Not at all strong" or "Extremely proud" vs. "Not at all proud"). The W-DEQgives prevalence ratings of intense fear of childbirth in approximately 10-15% of pregnant women (Lukasse, Schei, Ryding, & Bidens Study, 2014; Nieminen, Stephansson, & Ryding, 2009; Soderquist, Wijma, & Wijma, 2004), and very intense fear in 5-6% (Heimstad, Dahloe, Laache, Skogvoll, & Schei, 2006; Nieminen et al., 2009), with examples of much lower ratings of intense fear in some populations (e.g. 4.5% among Belgian primiparas and 3.6% in Australian multiparas; Lukasse et al., 2015; Toohill, Fenwick, Gamble, & Creedy,

2014). Repeated factor analyses of the instrument have revealed its multidimensional structure (Fenaroli & Saita, 2013; Fenwick, Gamble, Nathan, Bayes, & Hauck, 2009; Garthus-Niegel, Storksen, Torgersen, Von Soest, & Eberhard-Gran, 2011; Johnson & Slade, 2002; Lukasse et al., 2014). Limitations in cultural transferabil-ity and the length of the instrument have led to further criticism (Haines et al., 2015). In the abundance of non-validated instruments and questions designed to measure childbirth fear, a new instrument, the Fear of Birth Scale, FOBS (Haines, Pallant, Karlstrom, & Hildingsson, 2011) has been developed. In FOBS, the question, "How do you feel right now about the approaching birth?" is to be answered using two visual analogue scales, with the anchors (a) "calm" and "worried", and (b) "no fear" and "strong fear". FOBS is thus considerably shorter that the W-DEQ, asking directly for childbirth fear instead of measuring the concept indirectly via expectations. Thus far, prevalence studies using a FOBS cut off point of >50, find fear of birth in about 30% of pregnant women (Haines et al., 2011), and using a cut point of >60 revealed in a Swedish community sample childbirth fear in 18% of Swedish born and 37% of foreign born pregnant women (Ternstrom, Hildingsson, Haines, & Rubertsson,


Fear of childbirth is commonly framed as a phenomenon within the domain of anxiety (Huizink, Mulder, de Medina, Visser, & Buitelaar, 2004; Wijma et al., 1998), and clinical descriptions of childbirth fear are often characterized by symptom expressions resembling those of various emotional disorders. However, to our knowledge, findings relating childbirth fear to different parameters of anxiety have never been structurally aggregated and evaluated, and little is known about the psychological mechanisms underlying this problem.

Established psychological models of anxiety disorders typically include physiological, cognitive and behavioral components of anxiety. The physiological aspects of fear and anxiety include responses such as palpations, hyperventilation, dizziness etc. (Diagnostic and statistical manual of mental disorders: DSM-5TM (5th ed.), 2013), and typically interact with cognitive and behavioral components in driving and maintaining an anxiety response (e.g. Clark, 1986; James, 1884). The cognitive components include concepts such as

negative automatic thoughts (Beck, 1976; Clark & Wells, 1995), negative beliefs and expectations about oneself, others, the world or the future (Beck, 1976; Foa, Huppert, & Cahill, 2006), and disorder specific attentional biases for threatening stimuli (Mineka & Sutton, 1992; Williams, Mathews, & MacLeod, 1996). Catastrophiz-ing, or the tendency to exaggerate the possible negative aspects of future events is another relevant concept (Beck, 1976; Ellis, 1962), as is the related concept of pain catastrophizing that is used with regard to experiences of actual or anticipated pain (Sullivan, Bishop, & Pivik, 1995; Sullivan et al., 2001). Yet another example is the expectancy of personal mastery of a specific situation, self-efficacy, affecting the likelihood of exposing oneself to that particular situation (Bandura, 1977a).

By means of escaping from or avoiding unpleasant experiences, the behavioral components of anxiety function to avoid entering a state of anxious apprehension. Avoidance of private experiences such as thoughts, emotions, memories, and bodily sensations are commonly clustered using the term experiential avoidance (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). Avoidance of aversive experiences and emotions (e.g. avoidance of uncertainty) can also be sought by means of reassurance (Salkovskis & Warwick, 1986), e.g. from family and friends, care givers, bodily checks or other sources of information. When avoiding fear relevant cues, the subsequent relief in negative affect will increase the strength of the avoidant behavior (Bouton, 2007). In the long run, avoidance behaviors make alternative, nonthreatening experiences of the avoided stimulus unlikely (Mowrer, 1947), and thus prevents learning of adaptive behaviors.

Fears can be acquired by at least three major pathways (Rachman, 1977); by conditioning, in which a learned association develops when a specific object or situation (e.g. being in hospital or thoughts of delivery) is paired with aversive experiences (e.g. discomfort), by vicarious exposure (e.g. when watching someone else give birth), and by indirect transmission via information (e.g. horror stories about childbirth). Research on vicarious exposure (or observational learning) has successfully demonstrated that vicarious experiences can lead to both fear acquisition (Bandura, 1977b) and fear reduction (Bandura, 1977a).

The object of this article is to review the existing knowledge on childbirth-related fear from a psychological perspective, giving an overview and critical evaluation of the current knowledge regarding the specificity of the syndrome, the pathways of fear acquisition, and the physiological, cognitive, and behavioral aspects of this form of anxiety.

2. Method

A computer-based literature search was conducted for the period January 1, 2000 to August 12, 2015, using the two databases Medline and Psychinfo to search for peer reviewed articles written in English. Titles and abstracts were screened in order to find papers focusing on fear of childbirth. The search string, therefore narrowed down to the words childbirth AND (fear OR anxiety) in any field, resulted in 639 articles. Fig. 1 shows all steps in the selection process.

Inclusion criteria: to be included in the review studies had to include the concept of fear of childbirth/childbirth-related anxiety and relate fear to any other factor relevant for the understanding of the concept - antecedents (e.g. obstetric history and other background factors), consequences (e.g. mode of birth and birth outcomes) or correlates of fear (e.g. psychiatric symptoms and psychological traits), as well as qualitative descriptions of wom-ens' experiences of childbirth fear. This first selection, fulfilling the above criteria, rendered 116 papers, and another 20 articles were added after review of their bibliographies. In a second screening for

639 records identified through database search: titles and abstracts screened 523 abstracts excluded: did not meet inclusion criteria

116 abstracts included: review of bibliographies 20 additional records were identified and included

136 full-text-articles screened for eligibility 37 full-text-articles excluded: 13 not original research papers 18 not focusing on fear of childbirth 3 not individual characteristics 3 focusing on specific groups

99 full-text-articles assessed for quality: 81 quantitative studies 15 qualitative studies 3 mixed methods —1

10 full-text-articles excluded: 4 quantitative studies due to retrospective design 5 quantitative studies due to lack of fear of childbirth measures or definition 1 qualitative single case report

89 full-text-articles included in results: 32 longitudinal studies 33 cross-sectional studies 2 register studies 5 case-control studies 14 qualitative studies 3 mixed methods

Fig. 1. The number of articles considered in each step of the process of inclusion and exclusion.

eligibility 13 articles that were not original research papers were excluded, as were 18 articles in which the focus on fear of childbirth was not evident (e.g. focusing on the childbirth process or anxiety in general), three articles that did not focus on characteristics of the individual (e.g. midwives' perspectives on childbirth fear), and three articles focusing on specific groups (e.g. women with diabetes), leaving 99 full text articles for quality assessment.

None of the included studies were of experimental design. Exclusion criteria for the quantitative studies were retrospective design (excluding four papers), lack of measurement of childbirth fear or failure in describing how cases and controls were selected (excluding five papers). The only exclusion criterion for qualitative studies was case reports of one single case (excluding one paper). Studies using mixed methods were evaluated using the criteria for qualitative studies. This exclusion left 89 articles for analysis.

Results presented in identified articles were coded following the aims of this article, clustering results in five categories: syndrome specificity (results relating fear of childbirth to psychiatric care and diagnoses, and to different measures of anxiety and depression), pathways of fear acquisition (results describing antecedents to fear, perceived 'causes', and the vicious cycle perspective), physiological aspects (results describing physiological responses related to childbirth fear), cognitive aspects (results describing catastrophic perceptions or objects of fear, cognitive biases, and the role of self-efficacy) and behavioral aspects (results describing escape, avoidance, and reassurance seeking as strategies for coping with fear). Descriptions of all included studies can be found in Appendix 1-5 in Supplementary material.

3. Results

3.1. Fear of childbirth: a specific syndrome?

Twenty-seven studies addressed the specificity of childbirth fear (see Appendix 1 for study details in Supplementary material).

Fig. 2 shows the number of studies addressing associations between childbirth fear and different parameters of anxiety and depression. With few exceptions making results somewhat ambiguous, the overall findings point to positive associations between childbirth fear and both anxiety and depression.

In addition to these studies, we found eight studies generally showing a positive association with psychiatric diagnoses, care or medication (e.g. Andersson et al., 2003; Soderquist et al., 2004; Nordeng, Hansen, Garthus-Niegel, & Eberhard-Gran, 2012; Rouhe, Salmela-Aro, Gissler, Halmesmaeki, & Saisto, 2011). However, the global severity index of SCL-90R has been found to correlate with fear of childbirth only among nulliparous women (r = 0.57, p < 0.01), and in multiple regression analysis it was not a significant predictor of childbirth related fear at all (Pazzagli et al., 2015).

Associations between childbirth-related fear and various psychiatric syndromes, such as mood- and anxiety disorders, PTSD, psychosis, personality disorder, substance abuse, and eating disorder, with p-values ranging between 0.015 and <0.001, have generally been confirmed (Rouhe et al., 2011; Sieber, Germann, Barbir, & Ehlert, 2006; Soderquist et al., 2004; Andersson, Sundstrom-Poromaa, Wulff, Astrom, & Bixo, 2004), although others have failed to show such associations (Zar, Wijma, & Wijma, 2002).

3.2. Fear acquisition

In the fear of childbirth literature all three pathways of fear acquisition, as suggested by Rachman (1977) are represented. We also found results suggesting a possible vicious circle of fear.

3.2.1. Fear conditioning

We found five qualitative studies describing previous negative birth experiences as causes of fear, and 15 quantitative studies investigating associations between fear of childbirth during pregnancy and previous birth experiences. All studies are presented in Appendix 2 in Supplementary material, and Fig. 3 shows the number of studies investigating relationships between childbirth fear during pregnancy and previous birth experiences.

Birth mode has also been studied in relation to postpartum levels of fear (Appendix 2 in Supplementary material), showing modes of delivery and intervention at birth in general (Fenwick et al., 2009; Handelzalts et al., 2015), emergency Caesarean section (Nilsson, Lundgren, Karlstrom, & Hildingsson, 2012), and negative birth experiences (Handelzalts et al., 2015; Nilsson et al., 2012), to be related to an increased risk for, or levels of, postpartum fear.

Despite acknowledging the importance of previous birth mode in the development of childbirth fear, women's perceptions of a negative birth experience have been shown to be of even greater importance in explaining subsequent fear of childbirth (Nilsson et al., 2012). Results from St0rksen, Garthus-Niegel, Vangen, and Eberhard-Gran, 2013 show that as many as 77.5% of women reporting a previous obstetric complication neither considered the birth a negative experience nor developed fear of childbirth in the subsequent pregnancy. Other factors than the specific modes of delivery may therefore be of importance in determining if a complicated delivery will generate a negative birth experience and give rise to subsequent childbirth fear.

Fear of childbirth could also be conceptualised as a generalization of anxiety acquired through conditioning in another situation (e.g. abuse). We found six quantitative studies considering experiences of abuse or trauma, showing a mixture of different associations (Appendix 2 in Supplementary material). Fear of childbirth has been associated with self-reported childhood abuse in general as well as several specific forms of childhood abuse (Heimstad et al., 2006; Lukasse et al., 2010; Lukasse, Vangen, 0ian, & Schei, 2011), with odds ratios ranging between 1.30 and 5.30 (Lukasse et al., 2010,2011). Physical or sexual abuse in adult life or

Fig. 2. The number of studies addressing associations between childbirth fear and parameters of anxiety and depression, including reported correlations and Odds Ratios. 1Garthus-Niegel et al. (2011); 2Johnson and Slade (2003); 3Laursen et al. (2008); 4Rubertsson, Hellstrom, Cross, and Sydsjo, 2014; 5Saisto et al. (2001); 6Storksen et al. (2012); 7Alipour, Lamyian, Hajizadeh,and Vafaei, 2011; 8Beebe et al. (2007); 9Heimstad et al. (2006); 10Jokic-Begic et al. (2014);11 Pazzagli et al. (2015); 12Rydinget al. (1998); 13Spice et al. (2009); 14Soderquist et al. (2004); 15Wijma et al. (2002); 16Zaret al. (2001); 17Hall et al. (2009); 18Handelzalts et al. (2015); 19Raisanen et al. (2014); 20Waldenstroem et al. (2006); 21Huizink et al. (2004).

'Correlations between childbirth fear and the subscales of Anxiety Sensitivity Index: Physical concerns r=0.38 to 0.45 and Psychological concerns r= 0.22 to 0.39 (Jokic-Begic et al., 2014; Spice et al., 2009); Social concerns r=0.28 (Jokic-Begic et al., 2014). Physical concerns was the only subscale predicting childbirth fear using multiple regression analysis (Jokic-Begic et al., 2014; Spice et al., 2009).

''Clusters including Anxiety and Depression explained 8-27% of the variance in childbirth fear, at least in early and mid pregnancy (Huizink et al., 2004; Saisto, Salmela-Aro, Nurmi, & Halmesmaki, 2001).

lifetime sexual abuse has not been found predictive of childbirth fear (Heimstad et al., 2006; Schroll, Tabor, & Kjaergaard, 2011), while associations has been found between childbirth fear and expreiences of being abused (e.g. offended, disrespected, taken advantage of) while visiting health services (Lukasse et al., 2015).

3.2.2. Vicarious experiences

Two studies investigated the role of vicarious experiences for fear of childbirth, one showing nonsignificant associations (Stoll, Edmonds, & Hall, 2015) and one that such experiences reduce rather than enhance fear. Stoll and Hall (2013b), found that young women who had never given birth themselves but who had witnessed a live birth expressed less childbirth fear than women who had not (p< 0.001, Cohen's d = 0.52, 95% CI 0.30-1.23), indirectly supporting live modeling as a means of fear reduction.

3.2.3. Transmission via information.

We found five quantitative and five qualitative studies relating childbirth fear to information from different sources (Appendix 2 in Supplementary material)

Nine of the studies found information from family and friends to be of importance in the development of childbirth fear (Fenwick et al., 2009; Fenwick, Hauck, Downie, & Butt, 2005; Fisher, Hauck, & Fenwick, 2006; Melender, 2002a; Melender, 2002b; Sercekus & Okumus, 2009; Stoll, Hall, Janssen, & Carty, 2014; Tsui et al., 2007). In two factor analyses of perceived causes of childbirth fear, the factor 'negative stories' has been one of the most important factors, with eigenvalues of 2.5-2.6, explaining 16.4-17.4% of the variance (Melender, 2002a; Tsui et al., 2007). 'Having received alarming information' has been found an independent factor, explaining 9.2-11.9% of the variance in perceived causes of fear among pregnant women (Melender, 2002a; Tsui et al., 2007). The woman's own

(professional) knowledge as a perceived cause of fear, as suggested in three studies (Fenwick et al., 2005; Melender, 2002a, 2002b), could be understood as a result of learning by either vicarious experiences or transmission of information.

In three qualitative studies public discourse and information in the media have been described as influeninge childbirth expectations and childbirth fear among pregnant and postpartum women (Fenwick et al., 2005; Fenwick et al., 2009; Melender, 2002b). Likewise, media and school-based education have been found to negatively influence attitudes towards pregnacy among college students (Stoll et al., 2014; Stoll & Hall, 2013b; Stoll et al., 2015).

3.2.4. Primary and secondary fear of childbirth

The commonly used distinction between primary and secondary fear of childbirth (or primary vs secondary tokophobia, see Hofberg & Brockington, 2000; Hofberg & Ward, 2007) seems to suggest different pathways of fear acquisition in parous and nulli-parous women. However, we have not found any studies explicitly addressing the role of parity in fear acquisition. Instead, parity is generally investigated as a background varible influencing the level of childbirth fear. Differences in fear level between nulliparous and parous women during pregnancy have been addressed in 14 papers found in this literature overview (Appendix 2 in Supplementary material). One study showed results indicating that mean levels of fear were higher among nulliparas, although more parous women reported severe fear of childbirth (Nieminen et al., 2009), and one study showed that while the frequency of reporting "intense fear" was stable regardless of parity, the frequency of reporting "some fear" decreased and "no fear" increased with parity (Geissbuehler & Eberhard, 2002). Two articles (using the same database) failed to show any association between parity and fear level during pregnancy (Hildingsson, Nilsson, Karlstrom, & Lundgren, 2011; Nilsson

Fig. 3. The number of studies addressing associations between childbirth fear and previous birth mode and birth experiences, including reported Relative Risks and Odds Ratios.

CS = Caesarean section

1 Fenwick et al. (2009);2 Haines et al. (2011); 3Lukasse et al. (2011); 4Nieminen et al. (2009); 5Rouhe et al. (2009); 6Ryding et al. (2015); 7Raisanen et al. (2014); 8Nilsson et al.

(2012); 9Toohill, Fenwick, Gamble, and Creedy (2014); 10Waldenstroem et al. (2006); "Larsson et al. (2015); 12Saisto et al. (1999); 13Lukasse et al. (2010); 14Storksenet al.

(2013); 15Soderquist et al. (2004); 16Handelzalts et al. (2015).

et al., 2012). The remaining 11 studies reported significantly higher fear levels during pregnancy among nulliparous women, or an increased risk for nulliparous women to experience severe childbirth related fear.

Two of four articles considering differences in the postpartum level of childbirth fear, found that parity does influence fear levels during pregnancy, but not after delivery (Fenwick et al., 2009; Zar, Wijma, & Wijma, 2001). The other two articles (using the same data set) revealed quite the opposite pattern, with no differences in fear during pregnancy but a significantly higher prevalence of childbirth fear among primiparas compared to multiparas one year after childbirth (Hildingsson et al., 2011; Nilsson et al., 2012).

In sum, the overall evidence points to a significant role of parity in the understanding of childbirth fear, which is further supported by results showing different patterns in ranking of item-total correlations depending on parity - a difference that disappears following delivery (Wijma et al., 1998).

3.2.5. A vicious cycle of fear

In contrast to a simple dichotomization between primary and secondary fear of childbirth, with presumably different pathways of fear acqusition, the course of fear over time has been described in terms of a vicious circle (Wijma, Ryding, & Wijma, 2002; Zar et al., 2001). We found 11 studies investigating correlations of fear at different points in pregnancy, during childbirth, in the postpartum period, or over pregnancies (Appendix 2 in Supplementary material). All 11 studies (two of them reporting from the same data set) show significant associations of fear over time, with correlations ranging between r = 0.21 and r = 0.84 (Alehagen, Wijma, & Wijma, 2006; Kj^rgaard, Wijma, Dykes, & Alehagen, 2008; Ryding, Wirfelt, Wängborg, Sjögren, & Edman, 2007; Schroll et al., 2011; Wijma et al., 1998; Wijma et al., 2002). Levels of antenatal fear have been found predictive of postnatal fear scores (Fenwick et al., 2009; Zar et al., 2001), with odds ratios for reporting fear one year after delivery or in a subsequent pregnancy ranging from 4.4 to 6.24 (Larsson, Karlström, Rubertsson, & Hildingsson, 2015; Lukasse et al., 2011; Nilsson et al., 2012).

Is it plausible that fear at one point in time might negatively influence the experience of future stimuli, thus initiating a vicious circle of increased fear. We identified 21 articles investigating different outcomes related to childbirth fear during pregnancy, see Fig. 4 and Appendix 3 in Supplementary material. Although results diverge, a majority of studies indicate that childbirth fear has negative consequences during childbirth and in the postpartum period.

Combining these results, viewing fear development in terms of a vicious circle seem relevant. Fear of childbirth during pregnancy appears to be related to fear during labor and in the postpartum period, possibly also to differences in birth mode, a more complicated delivery, and a birth experience that is more negative. Further, a negative birth experience appears to be associated with an increased risk of childbirth fear in a subsequent pregnancy.

3.3. Physiological aspects

Physiological manifestations of childbirth fear are described in as few as six studies in the current review (Appendix 3 in Supplementary material). Sleep disturbances are described in five studies (Hall et al., 2009; Melender, 2002a; Nilsson & Lundgren, 2009; Sjögren, 1997; Tsui et al., 2007), tachycardia in three (Melender, 2002a; Nilsson & Lundgren, 2009; Tsui et al., 2007), tenseness, restlessness and nervousness in two (Melender, 2002a; Tsui et al., 2007), and finally nightmares (Sjögren, 1997) and stomach pains (Nilsson & Lundgren, 2009) in one study each. However, the potential role of these symptoms or experiences in the development and maintenance of fear has not been established.

3.4. Cognitive aspects

Although women with childbirth fear more commonly report having childbirth related thoughts compared with women with no fear (OR = 2.7, 95% CI 1.62-4.37; Hildingsson, Thomas, Karlström, Olofsson, & Nystedt, 2010), no single study with the agenda of exploring childbirth fear from a cognitive perspective was found. However, by examining the reported objects of fear among

Fig. 4. The number of studies addressing associations between childbirth fear during pregnancy and birth modes, complications and birth experiences during childbirth, including reported statistics.

1Heimstad et al. (2006); 2Hildingsson (2014); 3Raisanen et al. (2014); 4Waldenstroem et al. (2006); 5Adams et al. (2012); 6Fenwick et al. (2009); 7Handelzalts et al. (2015); 8Jespersen, Hegaard, Schroll, Rosth0j, and Kjsrgaard, 2014; 9Johnson and Slade (2002); 10Larsson et al. (2015); 11Laursen, Johansen, and Hedegaard, 2009; 12Reck et al. (2013); 13Ryding et al. (2015); 14Ryding et al. (1998); 15Sydsjo et al. (2013); 16Beebe et al. (2007); "Kjsrgaard et al. (2008); 18Pazzagli et al. (2015); 19Rouhe et al. (2011); 20Sieber et al. (2006);21 Wijma et al. (2002).

pregnant women, ideas about cognitive beliefs and expectations relating to pregnancy and childbirth may be inferred. We also found analogues of the two cognitive concepts self-efficacy and pain catas-trophizing, and one study identifying lower sense of coherence as a direct cause of childbirth fear (P = -0.89, p < 0.001; Takegata et al.,


3.4.1. Objects of fear

In all, 15 studies were found to consider objects of fear relating to childbirth (Appendix 4 in Supplementary material). In addition to differences in research design and study population, differences in factor structure, thematic organization and specificity make comparisons across these studies difficult. The reported findings are summarized in Table 1.

3.4.2. Self-efficacy and perceived stress coping ability

Eleven quantitative studies (Appendix 4 in Supplementary material) have investigated the role of self-efficacy or self-rated coping ability in fear of childbirth, with results generally being in line with the model suggested by Bandura (1977a).

Childbirth specific self-efficacy is commonly measured using the instrument Childbirth Self-Efficacy Inventory (CBSEI) and its two subscales; outcome efficacy and efficacy expectancy (Lowe, 1993). This inventory was related to different measures of childbirth fear in five studies. Results point to fear correlating negatively with total score of CBSEI, range r = -0.322 to r = -0.59 (Beebe, Lee, Carrieri-Kohlman, & Humphreys, 2007; Sieber et al., 2006), with the efficacy expectancy subscale, range r = -0.36 to r = -0.68 (Beebe et al., 2007; Lowe, 2000; Salomonsson, Gullberg et al., 2013; Schwartz et al.,

2015), and to a lesser extent with the outcome expectancy subscale, range r =0.191 to r = -0.337 (Salomonsson, Gullberg et al., 2013; Schwartz et al., 2015).

Both CBSEI and childbirth self-efficacy as a single item have been found to be significant predictors (p < 0.001) of childbirth fear (D'Cruz & Lee, 2014; Salomonsson, Gullberg et al., 2013), and lack of self-efficacy has been suggested as a separate factor in fear of childbirth using either exploratory (Lukasse et al., 2014), or both

exploratory and confirmatory, factor analysis (Garthus-Niegel et al., 2011) on W-DEQitems.

In three studies childbirth fear has been related to the individual's appraisal of her adaptive resources to cope with stressful situations, using the Stress Coping Inventory, SCI (Ryding, Wijma, Wijma, & Rydhstrom, 1998), showing significant between group differences (Ryding et al., 1998; Soderquist et al., 2004). An increased risk of childbirth fear during pregnancy has been reported among women, indicating low stress coping ability, OR = 1.8,95% CI 1.1-2.8, p = 0.01 (Soderquist et al., 2004), while other results suggest that it does not predict fear of childbirth in the postpartum period (Wijma et al., 2002).

Self-efficacy or perceived stress coping ability was addressed in four of the qualitative studies of childbirth fear included in this review (Appendix 4 in Supplementary material). In one of these, the expectations of imminent childbirth among women with severe fear of childbirth was compared before and after eight weeks of internet-based cognitive behavioral therapy. The authors concluded that participating women described a more realistic attitude towards childbirth, more self-confidence and more active coping strategies following the intervention (Nieminen et al., 2015).

3.4.3. Pain catastrophizing

One article discussed pain catastrophizing in relation to childbirth fear, suggesting that pain catastrophizing could play a role by mediating the relationship between fear of pain and the preference for elective Caesarean section (Dehghani, Sharpe, & Khatibi, 2014).

3.5. Behavioral aspects

Logically, the most radical form of avoidance relating to childbirth fear would be complete avoidance of pregnancy or postponing of pregnancy, which was found in four studies (Appendix 5 in Supplementary material). Nine to eleven percent of pregnant women report having postponed the current pregnancy due to fear, or had considered ending it through abortion (Tsui et al., 2007). The wish to avoid an ongoing pregnancy or forthcoming childbirth has been found to explain 10.2-12% of the variance in manifestations

Table 1

Objects of fears described in the literature, including number of articles addressing each theme, reported frequencies and explained variance in factor analyses.

Fears relating to Number of Frequency in general Frequency in FOC Explained variance in factor

identified studies population population analysis

The childbirth process 131-13 71-97.4%2,6 19.8-21.3%6,7,12

emergency interventions, 6.3-13.3%5 6%7

anesthesia and hemorrhage

fear of pain 33-39.8%5,8 44-65%8,10

The life and wellbeing of the 121-7,9-13 29-93.9%2,5,6 10.5-14.5%6,7,12

mother and baby

maternal death 5%2 92,10

infant death 3010

maternal and infant death 1610

Own capabilities and reactions 71,2,4-6,10,11 37-86.8%2,6 4410 4.2%6

during childbirth including

losing control

Uncertainty including 53,4,9,11,14,15

unpredictability and the lack of


The competence and behavior 92,5-10,12,13 20-90.1%2,6 73%10 8.3-12.3%6,7,12

of health care personnel

powerlessness and inability to 13.2-18%5,8 42-61%8,10

influence events

The future role and life 63,6,7,9,10,12 67.8%6 7.1-11.1%6,7,12

including sexuality, the

maternal role, the partner

relationship, and the child's


Other themes

integrity, privacy, exposedness 21,11

partner's capabilities and 22,3 2%2

reactions during childbirth

Note. FOC = Fear of Childbirth

1 Areskog, Uddenberg, and Kjessler, 1981; 2Eriksson, Westman, et al. (2006); 3Fenwick et al. (2009); 4Fisher et al. (2006); 5Geissbuehler and Eberhard (2002); 6Matinnia et al. (2015); 7Melender (2002a); 8Ryding et al. (2007); 9Serceku? and Okumus (2009); 10Sjögren (1997); "Stoll & Hall (2013a); 12Tsui et al. (2007); 13Tugut, Tirkes, and Demirel, 2015; 14Melender (2002b); 15Nilssonand Lundgren (2009).

of fears among pregnant women reporting childbirth-related fear (Melender, 2002a; Tsui et al., 2007), and the time elapsed since the preceding delivery has been found longer for parous pregnant women in fear of childbirth counseling compared to non-fearful controls (OR 1.22-1.44; Saisto, Ylikorkala, & Halmesmäki, 1999; Sydsjö et al., 2013).

Regarding avoidance of vaginal delivery, we found 15 quantitative and two qualitative studies reporting fear of childbirth in relation to preferences for Caesarean section as mode of birth (Appendix 5 in Supplementary material). Fear levels have repeatedly been found to be higher among women preferring Caesarean section as birth mode (D'Cruz & Lee, 2014; Dehghani et al., 2014; Haines et al., 2011; Matinnia et al., 2015; Nieminen et al., 2009; Rouhe, Salmela-Aro, Halmesmaeki, & Saisto, 2009). However in the study by Haines et al. (2011) there were two samples, one of them not showing significant differences. Also, students preferring Caesarean section as a future mode of birth report higher levels of fear (Stoll et al., 2014). Likewise, a positive association has been found between level of childbirth fear and the tendency to wish for, or request a Caesarean section (Hildingsson et al., 2011; Kringeland, Daltveit, & Moeller, 2009; Lukasse et al., 2011; Ryding et al., 2015; Salomonsson, Gullberg et al., 2013; Stoll et al., 2015), with reported odds ratios and relative risks ranging between 3.84 and 11.6 (Hildingsson et al., 2011; Kringeland et al., 2009; Lukasse et al., 2011; Stoll et al., 2015). Qualitative results also indicate a relation between high levels of fear and the wish for birth interventions (Stoll & Hall, 2013a), and that women with childbirth fear perceive Caesarean section as a way of enhancing control over the birth process, offering safety and alleviation of fear (Fenwick, Staff, Gamble, Creedy, & Bayes, 2010).

Seven quantitative longitudinal studies (Appendix 5 in Supplementary material) have explored the association between childbirth fear and rates of actual Caesarean sections, six of these

indicating a positive relation. Five articles (two of them reporting findings from the same study) indicate that elective Caesarean sections are more common among women fearing childbirth (Hildingsson, 2014; Larsson et al., 2015; Ryding et al., 2015; Sydsjo et al., 2013; Waldenstroem, Hildingsson, & Ryding, 2006) with odds ratios ranging between 1.66 and 5.6 (Hildingsson, 2014; Larsson et al., 2015; Ryding et al., 2015). Higher fear levels among women requesting a Caesarean section compared to women opting for vaginal delivery are shown in one study (Handelzalts et al., 2012), while another finds no differences in fear levels according to subsequent mode of birth (Johnson & Slade, 2002).

Regarding specific types of avoidance, (e.g. avoidance of pain), results are equivocal (Appendix 5 in Supplementary material). Although a stronger wish to avoid pain has been reported among women with childbirth fear (Hildingsson, 2014), the relation between fear of childbirth and use of epidural analgesia (EDA) is not straightforward, with three studies suggesting a positive relation (Adams, Eberhard-Gran, & Eskild, 2012; Saisto et al., 1999; Stoll et al., 2014), one study failing to show differences in fear (Alehagen et al., 2006), and two showing ambiguous results (Fenwick et al., 2009; Raisanenet al., 2014). Many pregnant women have also been found to fear either epidural or general anesthesia (13.0% and 11.8% respectively; Geissbuehler & Eberhard, 2002).

Other forms of behavioral avoidance, not specifically relating to the process of giving birth, are not as well described in the literature. Results from three qualitative studies show what could be labeled experiential or cognitive avoidance, in which women with fear of childbirth try to avoid thoughts and memories that are related to their fears (Beck & Watson, 2010; Eriksson, Jansson et al., 2006; Nilsson & Lundgren, 2009). These studies also describe how pregnant women try to avoid their fear by not talking about it (Nilsson & Lundgren, 2009) or by avoiding situations that might trigger fear or anxiety responses (Eriksson, Jansson, & Hamberg,

2006). This kind of avoidance is exemplified when women with childbirth fear avoid ultrasounds and medical examinations (Beck & Watson, 2010), avoid opportunities to receive information about childbirth, or refuse to participate in parental educational groups (Eriksson, Jansson, et al., 2006).

More subtle strategies to avoid, alleviate or cope with fear (e.g. seeking information about pregnancy and childbirth, checking fetal movements, and seeking medical help and reassurance in the form of tests, examinations, information, guarantees, and support) are anecdotally described (Beck & Watson, 2010; Eriksson, Jansson, et al., 2006; Melender, 2002a, 2002b; Tsui et al., 2007). Even if the short term result of engaging in these activities would be fear relief, no study investigating long-term effects of reassuring activities on fear of childbirth was found.

4. Discussion

The objective of the current review was to examine the literature on fear of childbirth from a psychological perspective. Specifically, the study sought to address the specificity of this fear, its pathways of fear acquisition, and its physiological, cognitive and behavioral manifestations.

Overall, few studies were found to demonstrate a clear-cut psychological perspective on fear of childbirth. Instead ideas about psychological mechanisms often had to be derived from studies with other objectives. Also when psychological concepts were considered, a stable foundation in psychological theory was often lacking. None of the included studies used an experimental design, and although one third of the studies were of longitudinal design, a predominance of analyses relevant for the understanding of childbirth fear were based on cross-sectional data. Definitions of the concept under investigation were not coherent, and the included studies used a wide array of operationalizations of included variables. Altogether, this makes it difficult to draw conclusions about the etiology of childbirth fear and its psychological mechanisms.

The descriptions of fear acquisition suggest that both fear conditioning and indirect transmission via information might be pathways to consider in the development of childbirth fear. The role of observational learning is yet largely unexplored. The vast majority of studies investigating the possible role of fear conditioning focus on previous childbirth experiences and are therefore conducted only among parous women. We did not find one single study examining the possibility of these women experiencing fear also prior to, or during, their first pregnancy. In fact, among all the included studies only one has monitored levels of fear over two pregnancies (Lukasse et al., 2011). Hence, it could be argued that the distinction between primary and secondary fear of childbirth is premature. A possible vicious circle in fear of childbirth has been suggested before (Wijma et al., 2002; Zar et al., 2001), and our review makes us inclined to agree. Women with high antenatal levels of childbirth fear might have an increased risk of experiencing fear during labor and appraise an ongoing delivery as threatening. This might increase the odds of having a negative birth experience and reporting childbirth fear in the postnatal period or in a subsequent pregnancy. Hence, fear of childbirth in parous women, might also be the result of a complex process, with several factors interacting over time. Likewise, fear of childbirth among nulliparous women must not necessarily be the result of indirect transmission of fear. Given the positive association between childbirth fear and general symptoms of anxiety and depression (e.g. Laursen, Hedegaard, & Johansen, 2008; Raisanen et al., 2014; Storksen, Eberhard-Gran, Garthus-Niegel, & Eskild, 2012), as well the emerging association with previous experiences of abuse (Heimstad et al., 2006; Lukasse et al., 2010; Lukasse et al., 2011), childbirth fear among nulliparous women could possibly also be the result of a

generalization of other anxieties. Since a biopsychosocial perspective, comprising several etiological factors, is typical for clinical anxiety (Barlow & Durand, 2015), a complex etiology also for childbirth related anxiety would be of no surprise.

In the existing literature the cognitive aspects of childbirth fear are for the most part represented by studies describing the content of fears among pregnant women. These studies reveal a great variety of future-oriented fears, that depending on the subjective appraisal of the woman, easily could be linked to the objects of fear typical for many anxiety disorders (e.g. generalized anxiety disorder, illness anxiety disorder, specific phobias of blood, injections, injuries or hospitals, social anxiety disorder and panic disorder).

The reported fear objects could also be used to generate ideas about the cognitive processes possibly maintaining fear. Based on the results, the cognitive concepts self-efficacy, pain catastro-phizing and intolerance of uncertainty might be of relevance in the understanding of childbirth fear. While associations between self-efficacy and childbirth fear have been investigated in a few studies, the role of the two other concepts remains to be understood. The few studies directly investigating catastrophizing in relation to childbirth suggest that pain catastrophizing is not only of importance for the anticipation of childbirth pain, but also associated with fear of being overwhelmed by pain (Van den Bussche, Crombez, Eccleston, & Sullivan, 2007), preferred mode of birth (Dehghani et al., 2014), the experience of pain intensity during delivery, and poorer physical recovery following childbirth (Flink, Mroczek, Sullivan, & Linton, 2009). Regarding intolerance of uncertainty, even less is known. This concept was originally established as one of the mechanisms explaining worry in generalized anxiety disorder (Dugas, Gagnon, Ladouceur, & Freeston, 1998; Freeston, Rheaume, Letarte, Dugas, & Ladouceur, 1994), but has in recent research been identified as a transdiagnostic feature across anxiety disorders and depression (Carleton et al., 2012; Gentes & Ruscio, 2011; McEvoy & Mahoney, 2012). In this review, fears relating to uncertainty were reported in several studies investigating objects of fears, and also suggested a distinctive concept in the W-DEQ (Wijma et al., 1998). As Cheung, Ip, & Chan, 2007 found feelings of control during labor to be negatively correlated with maternal anxiety, studies addressing intolerance of uncertainty as a mechanism in fear of childbirth would be highly interesting.

Although possibly of interest, the physiological aspects of childbirth fear have not been a prioritized area of research. Domschke, Stevens, Pfleiderer, & Gerlach, 2010 argue that the heightened inte-roceptive sensitivity seen in individuals with elevated trait or state anxiety, anxiety sensitivity or anxiety disorders, increases the number of perceived bodily sensations that may be misinterpreted in a catastrophic manner, resulting in a vulnerability for anxiety responses and disorders. Individual differences in interoceptive sensitivity and correlates of such differences have not, to our knowledge, been investigated in a pregnant population. However, physiological aspects of the related concept anxiety sensitivity, i.e. the belief that anxiety experiences are dangerous or have negative implications (Reiss, Peterson, Gursky, & McNally, 1986), have been positively associated with childbirth fear (Jokic-Begic, Zigic, & Rados, 2014; Spice, Jones, Hadjistavropoulos, Kowalyk, & Stewart, 2009). Anxiety sensitivity has further been found predictive of experiences of pain during labor (Carvalho, Zheng, & Aiono-Le Tagaloa, 2014; Curzik & Jokic-Begic, 2011; Lang, Sorrell, Rodgers, & Lebeck, 2006), and experimental pain studies have identified an interpretive bias of ambiguous information as a possible cognitive mechanism accounting for the association between anxiety sensitivity and experimental pain (Keogh & Cochrane, 2002; Vancleef, Hanssen, & Peters, 2016). Such interactions between heightened sensitivity for internal cues and catastrophic interpretive biases may thus be of interest in future studies of mechanisms underpinning childbirth fear.

Behavioral aspects such as escape, avoidance and reassurance are of great importance in understanding the maintenance of anxiety disorders, and both high state anxiety and pregnancy-specific distress have been found to predict avoidance as a general strategy for coping during pregnancy (Hamilton & Lobel, 2008). Despite the possible importance of behavioral factors, this perspective too has been quite overlooked with regard to fear of childbirth. In fact, we did not find one single study directly addressing avoidance or reassurance in relation to childbirth fear. However, when screening the literature for clues regarding these areas, some interesting themes emerged. The association between fear of childbirth and preferred, requested, and actual mode of birth could probably be understood in the light of avoidance of vaginal delivery. The odds ratio of preferring a Caesarean section has recently been found to be almost twice as high as actual delivery by one (OR 4.6, 95% CI 2.9-7.3 vs. OR 2.4, 95% CI 1.2-4.99; Storksen, Garthus-Niegel, Adams, Vangen, & Eberhard-Gran, 2015), indicating other factors (e.g. medical risk factors) to be of greater importance in determining mode of birth and each woman's opportunities to avoid a vaginal delivery.

When relating fear of childbirth to different measures of anxiety and depression, as well as to psychiatric diagnoses, care and medication, all studies identified support some degree of positive association. Correlations range from small to large (r = 0.22 to r = 0.59, OR = 2.3-11.0; see Fig. 2), none of them indicating that fear of childbirth could be completely accounted for by another variable or set of variables. Building on correlational results like these, fear of childbirth has been suggested to constitute a relatively distinctive syndrome, yet within the domain of anxiety (Huizink et al., 2004; Johnson & Slade, 2002; Wijma et al., 1998). However, childbirth-related fear or anxiety, as measured with the W-DEQand PRAQ-R, does not seem to be a coherent construct, but rather a multidimensional phenomenon (Fenwick et al., 2009; Garthus-Niegel et al., 2011; Huizink et al., 2004; Johnson & Slade, 2002; Lukasse et al., 2014). Still, even if we could capture childbirth fear as a unidimensional construct (e.g. by using the FOBS), the group of women reporting such fear would probably still be quite heterogeneous in terms of fear manifestations, etiology and maintaining factors. This would imply that fear of childbirth perhaps not is the appropriate level for analysis, or at least not the most helpful one for treatment purposes. The heterogeneity of the group of women expressing fear of childbirth has been sparingly studied, and the possibility of within group differences, cancelling each other out in between group analyses needs further investigation. At this point then, conclusions regarding both the specificity and the cohesiveness of the phenomenon seem premature.

The clinical implications of adopting a multidimensional perspective on fear of childbirth, acknowledging the possibility of heterogeneity in etiology, manifestations, and mechanisms, would be to individualize the treatment following a thorough assessment of the unique circumstances of each woman. Recent research suggests that psycho-educational interventions might be effective in reducing childbirth-related fear (Rouhe et al., 2015; Salmela-Aro et al., 2012; Toohill, Fenwick, Gamble, Creedy, Buist, et al., 2014) and qualitative results suggest that internet-administered self-help, based on cognitive behavioral therapy, may have an effect on fearful women's attitudes, self-confidence and coping strategies relating to childbirth (Nieminen et al., 2015). Nonetheless, the number of intervention studies is limited, and since the mechanisms underpinning childbirth fear are not thoroughly explored, these interventions are likely to be based more on clinical impressions and expertise than empirically derived models of anxiety. Emphasizing a psychological perspective on fear of childbirth has the potential of contributing both to a deepened scientific understanding of this form of anxiety, and to the development of clinical interventions based on functional analysis of the etiological and maintaining factors contributing to fear for each individual.

This narrative review has identified three areas of research that seem to be of potential interest and importance to the field, namely systematic investigations of psychological mechanisms such as avoidance, reassurance and cognitive biases in fear of childbirth, longitudinal studies over more than one pregnancy exploring possible vicious circles, and within group comparisons ofpsychological characteristics among women fearing childbirth. Empirical knowledge about these aspects would be ofgreat benefit in understanding the phenomenon of childbirth-related fear, and in developing interventions that might be helpful for the large number of women experiencing anxiety of this kind.

Appendices 1-5. Supplementary data

Supplementary data associated with this article can be found, in the online version, at 10.007.


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