Saisto, Terhi MD; Salmela‐Aro, Katariina PhD; Nurmi, Jari‐Erik PhD; Könönen, Teija; Halmesmäki, Erja MD, PhD
Of all parturients, 6–10% suffer from fear of labor, expressed as nightmares, physical complaints, and difficulties concentrating on work or family activities.1 Maternal anxiety also influences the course and outcome of pregnancy, in the form of preterm and postterm delivery, fetal growth restriction, and asphyxia,2–5 and high risk of emergency cesarean.6 Moreover, anxiety, distress, and depression during pregnancy are associated with puerperal depression and impaired postnatal maternal attachment.7,8 Fear of childbirth often implies a request for elective cesarean, despite the known risks of this procedure.9 Thus, to reduce fear and anxiety, as well as the morbidity both of women and infants due to obstetric complications and unnecessary cesareans, treatment for fear and anxiety should be established in modern antenatal outpatient clinics.
We randomly assigned women who were referred for antenatal consultation because of fear of childbirth to receive either intensive or conventional treatment. The primary goal of this study was to evaluate the possibility of reducing requests for cesarean without coercing the women into vaginal delivery. The other outcome measures were changes in pregnancy‐ and delivery‐related anxiety and concerns, puerperal depression, and satisfaction with the childbirth experience.
MATERIALS AND METHODS
Between August 1996 and July 1999, a total of 176 obstetrically low‐risk and physically healthy pregnant women were referred to the outpatient clinic of the Department of Obstetrics and Gynecology in Helsinki University Central Hospital because of fear of vaginal delivery, as diagnosed by a specific questionnaire10,11 (Table 1). The cut‐off point for diagnosis of fear of childbirth was five or more affirmative answers or request for cesarean. The only exclusion criterion was a contraindication to vaginal delivery at the time of randomization (two previous cesareans or vertical incision in previous cesarean). The study was approved by the local ethics committee.
At the time of the first appointment and signing of an informed consent, the women were interviewed by T.S. and randomly assigned to groups in balanced blocks of 20 by sealed opaque envelopes (including the code for one of the two possible groups). The groups consisted of an intensive therapy group or a conventional therapy group, separately for the nulliparous and parous women.
All women received three questionnaires to complete (the first before the randomization, the second 4 weeks before the due date, and the third 3 months after the delivery). Completing the questionnaires was recommended but emphasized as only voluntary and would not influence their care (Table 2). However, filling in or refusing to fill in the questionnaires was considered an indication of the woman's motivation for treatment and confrontation of her fears.
The two questionnaires during pregnancy consisted of a revised version of Beck's Depression Inventory12 (Cronbach alpha reliability 0.89), a Pregnancy Anxiety Scale10,13 (alpha 0.73), and a revised version of the Personal Concerns scale,14 in which the women were asked the following question: “People have many kinds of worries, fears, or difficult things. What kind of personal concerns do you have in your life at the moment?” They were given three lines for their responses.14 In content analysis of this open question, each concern mentioned by the woman on each occasion was classified, on the basis of its content, independently by two assessors into one of five categories (birth, achievement, family, self, and other), which are similar to those in earlier studies.14 The reliabilities measured by percentage of agreement between the two independent assessors were 95% and 96%. In this study we concentrated on birth‐related concerns.
The postnatal questionnaire was similar to those used during pregnancy but was combined with obstetric data and eight questions about satisfaction with childbirth (about the childbirth being a positive or painful experience, and about sufficient pain relief, support from partner and personnel, and about feeling safe and able to influence the treatment without being patronized by personnel, with each question having five responses) (alpha 0.78). Mode of delivery, duration of labor, and pain relief used during labor was determined from patient records. Duration of labor was defined from initiation of regular contractions more often than once in 10 minutes to the delivery of the infant.
Before the study, the obstetrician responsible for the study (T.S.) had attended a 185‐hour course of cognitive therapy (Institute for Cognitive Therapies, Turku, Finland) and one of 40 hours in childbirth psychology (Tampere University, Finland) and was qualified as a therapist. In addition, she had several years' experience in treating women suffering from fear of childbirth.
Therapy in the intensive therapy group consisted of provision of information and conversation regarding previous obstetric experiences, feelings, and misconceptions. The appointments were based on routine obstetric check‐ups to assure the normal course of the pregnancy, combined with cognitive therapy, the main principles of which are focus on one target problem involving the active role of the therapist and reformulation of the problem during a limited time. Psychotherapy is reflective action aimed at teaching the patient to see her problem in an altered way (self‐reflection) and to change her particular target‐problem procedures by cognitive and behavioral exercises.15
An appointment with the midwife (T.K.) and visits to the obstetric ward were recommended to provide more practical information about pain relief and possible interventions (vacuum, scalp blood sample, etc.) during labor and delivery. All women were allowed to phone T.S. or T.K. between sessions. Written information was given at the first session regarding the pros and cons of vaginal delivery and of cesarean, as well as information about alternative modes of pain relief available at our hospital. At the last appointment before delivery, the woman's personal written wishes related to delivery were discussed and attached to her records. If the woman still requested a cesarean, the operation was arranged to be done 1 week before the due date.
Therapy in the conventional therapy group consisted of standard information distribution and routine obstetric check‐ups, as well as provision of written information about the pros and cons of vaginal delivery versus cesarean, and the pain relief that is offered at our hospital. Protocols for treatment are shown in Table 3.
Power analysis performed to calculate the number of patients needed to achieve a significance level of .05 with 90% power based on the frequency of cesarean in this kind of patient group from Ryding 16 and Sjögren and Thomassen17 showed that 74 patients were needed in each group to show a 50% reduction in cesarean rate, which was our primary outcome variable.
Analysis of the outcome measures (mode of delivery, duration of labor, pregnancy‐related anxiety, and related concerns after therapy, satisfaction with childbirth, and puerperal depression) were made by intention to treat; women remained in the group to which they were originally assigned. Data from the questionnaires were combined with obstetric data.
Data were compared with the SPSS program (SPSS Inc., Chicago, IL), first by Student t test, with or without logarithmic transformation, when compatible (duration of labor, satisfaction with delivery), and by the χ2 test for nonparametric data (mode of the delivery). To be able to use more independent variables in comparison of modes of delivery, we chose to use log‐linear analysis, a multivariable method for categoric variables that analyzes different types of relationships among several variables. Further, two‐way repeated analysis of variance (ANOVA) was used to evaluate the effect of therapy on the Pregnancy Anxiety Scale and on birth‐related concerns. Finally, to characterize the factors contributing to puerperal depression and to low motivation to treatment, we used logistic regression analysis with an adjusted odds ratio (OR) and its 95% confidence intervals (CI).
In total, 112 women (64%) completed all three questionnaires (participants); percentages were distributed similarly in both groups (Table 2). All the women were of Finnish background, spoke Finnish, were middle or upper social class, and from the urban capital area of Helsinki. In logistic regression analysis, those who did not complete the questionnaires (nonparticipants) were characterized by older age (adjusted OR 0.93 [95% CI 0.87, 1.00], P = .045), fewer appointments (adjusted OR 2.03 [95% CI 1.30, 3.21], P = .003), and random assignment to the conventional therapy group (adjusted OR 2.70 [0.98, 7.43, P = .054]), but they differed from participants neither in score for fear of delivery nor in parity. Regardless of therapy group, at the beginning the nonparticipants had requested cesareans more often (78% compared with 62%, P = .015).
After the therapy appointments, 62% of all of those originally requesting cesareans (n = 117) chose to deliver vaginally. The participant flow and the final mode of delivery are shown in Figure 1. Cesarean for psychosocial reasons was chosen by 20 women in the intensive therapy group (36% of those primarily requesting it) and by 26 women in the conventional therapy group (41%, P > .05). Parity was related to request for cesarean: 74% of parous and 59% of nulliparous women requested it in the beginning (P = .003), and of them 42% of parous and 32% of nulliparous women also finally chose it (P > .05). In the log‐linear model, the parous women in the conventional therapy group chose cesareans for psychosocial reasons more often than expected (Table 4).
Of the nonparticipants who requested cesareans at the beginning, 57% chose cesareans at the end of pregnancy, compared with 27% of analogous groups of participants (P = .001). This difference was verified in a log‐linear model (Table 4), where, when summarized together, nonparticipants chose cesarean more often than expected, as did parous women and women in the conventional therapy group, although the difference between the observed and expected numbers of cesareans was significant only in parous nonparticipants in the conventional therapy group (standardized residual 2.54, P = .011). In the intensive therapy group, where all women were offered an appointment with a midwife, 35% of those who refused to use this opportunity chose cesareans compared with 10% among those who visited the midwife (P = .008).
In the first questionnaire before randomization the women in the intensive therapy group mentioned birth‐related concerns more frequently (mean 0.56 ± 0.54) than did those in conventional therapy group (mean 0.38 ± 0.56, P = .022). After therapy, in late pregnancy, birth‐related concerns in the intensive therapy group had decreased, but in the conventional therapy group they had increased. In two‐way repeated ANOVA, this interaction between birth‐related concerns and group was significant (P = .022) (Figure 2).
In both groups in early pregnancy, pregnancy‐related anxiety was high (Figure 2). During therapy the mean score for pregnancy‐related anxiety tended to decrease in the intensive therapy group but not in the conventional therapy group, although the difference was not statistically significant. During therapy the mean score for fear of pain in labor (question 4 in Pregnancy Anxiety Scale) decreased significantly in the intensive therapy group (from 4.7 ± 0.6 to 4.4 ± 1.0) compared with the conventional therapy group (increase from 4.4 ± 0.9 to 4.5 ± 1.1, linear interaction between group and time in two‐way repeated ANOVA [P = .041]). During therapy the mean score for fear of the obstetrician's unfriendly behavior (question 9 in Pregnancy Anxiety Scale) decreased in the intensive therapy group (from 2.9 ± 1.4 to 2.6 ± 1.2) compared with the conventional therapy group (increase from 2.8 ± 1.3 to 2.9 ± 1.4, linear interaction between group and mean score in two‐way repeated ANOVA [P = .054]). Results remained the same after effects of depression and parity had been controlled for.
In women delivering vaginally, labor was shorter in the intensive therapy group (mean 6.8 ± 3.8 hours from the beginning of the regular contractions more often than once in 10 minutes to delivery of the infant) than in the conventional therapy group (8.5 ± 4.8 hours, P = .039). The time from start of labor to possible emergency cesarean was not significantly different between groups (data not shown). There was no difference between the groups in the use of epidural analgesia: it was used in 85% of vaginal deliveries in the intensive therapy and in 82% in the conventional therapy group.
Overall, childbirth was experienced as positive, the mean score being 3.7 ± 1.4 in the intensive therapy group and 4.0 ± 1.3 in the conventional therapy group (scale from 1 to 5, P > .05). The women answered questions similarly except for one question: women in the intensive therapy group remembered not having felt as safe as did women in the conventional therapy group (mean scores 3.9 ± 1.2 and 4.3 ± 0.8, scale from 1 to 5, P = .02), a difference in nulliparous but not in parous women. The results remained the same even after depression and parity were controlled for.
During puerperium, the groups did not differ from each other in the amount of depression. In logistic regression analysis, risk of puerperal depression (score above the 90th percentile) was highest among those with earlier depression, both in early pregnancy (adjusted OR 4.14 [95% CI 1.23, 13.91] and before childbirth adjusted OR 34.12 [95% CI 1.73, 671.81]), similarly in both groups, even when parity, age, fear of delivery, pregnancy anxiety, satisfaction with delivery, and mode of delivery were all controlled for.
The question as to the right to choose a cesarean without a medical indication is of the utmost relevance: on the one hand, because of universally growing cesarean rates, and on the other, because of the fundamental medical principle of not to harm but to benefit the patient.18,19 The main goal of this study was to evaluate the possibility of reducing requests for cesareans by helping women choose vaginal delivery without fear. We found this possible by personal cognitive therapy.
Conversely, compared with pregnant women in general, our patients were very anxious about the delivery. In our earlier unselected pregnant population only 6% of women had nightmares about childbirth,10 their mean score for fear of delivery was low (2.1 ± 2.1), and a third of those women were unafraid of delivery.20 In addition, in that population,20 mean score for pregnancy‐related anxiety was 22.4 ± 6.8 compared with 32.0 ± 7.3 in the present study. Our current patients can thus be regarded as a sample of women with abnormal and exceptional fear of childbirth. In Finland, for the past decade, severe fear of childbirth has been considered an indication for cesarean, and in the year 2000, 8% of all cesareans done at Helsinki University Hospital were for that reason.
At least three limitations should be considered when generalizing the findings of this study. First, this research was carried out in a country with highly emancipated, mostly full‐time working women with nearly equal rights with men and with public health services that encourage women to express their feelings and wishes openly. The second limitation is a phenomenon common in clinical trials and especially in the field of psychotherapy research21,22: accepting the therapy and following the randomized study protocol. An example of this is the relatively low response rate to the questionnaires. The third limitation was ethical; as we could not leave any of the referred women neglected, women in the conventional therapy group had to receive some therapy as well. However, we have shown here that repeated visits and structured cognitive therapy for fear of childbirth is not a waste of time: its benefits can be seen in fewer concerned patients and in successful short labors.
In preparation for childbirth, training in relaxation and methods of coping with pain are essential for successful labor.23,24 We found that birth‐related concerns and pregnancy‐related anxiety tended to decrease in the intensive therapy group. Shorter labors in less anxious women also can be seen as a consequence of better relaxation and self‐assertion. These effects can affect long‐term health and thus even have positive economic consequences, as general well‐being among these women increases.
Asking patients about personal concerns is not common in obstetrics but seems to be a sensitive method for studying childbirth‐related anxiety. Personal concerns stem from a woman's spontaneous thoughts related to childbirth, unlike structured statements in formal questionnaires and scales. Because personal concerns are sensitive to change, asking about them can serve as a sensitive diagnostic method to evaluate change in pregnancy‐related anxiety and in response to therapy.21
Our therapy was based on the approach of cognitive therapy, some lessons of which might be beneficial for all doctors. The cognitive approach suits well the treatment of fear of childbirth because of its short duration and focus on one target problem. The cognitive‐behavioral approach teaches the patient constructive thinking, which reduces anxiety both directly and indirectly by reducing perception of stress,25 and it increases positive adaptation to pregnancy, which is significantly related to general well‐being.26,27
The effects of therapy on anxiety and fear of childbirth can be measured in terms of alleviation of perceived stress and better adjustment during pregnancy, but also as withdrawal of the request for a cesarean. In our study the number of women who withdrew their request for a cesarean was high (62%), even with minimal therapy (conventional therapy group). This good result is in accordance with previous Swedish studies where after one to 13 sessions of counseling or short‐term therapy, nearly half of women requesting a cesarean chose vaginal delivery.16,17 In parous women, fear of delivery, however, might be a form of posttraumatic stress disorder or intrusive stress reaction, both of which can occur after painful childbirth and emergency cesarean.28,29 Long‐lasting therapy is needed for treatment of that type of posttraumatic stress disorder, and the treatment should have been initiated before a new pregnancy.
The problem of low motivation for therapy, also seen in our study, is difficult to overcome.16 Some women just want a cesarean without any discussion or counseling from the obstetrician. As observed in our hospital, such women tend to cancel appointments and change obstetrician or hospital in order to avoid deeper evaluation. Unfortunately, it is difficult to help these women because of their reluctance to express their concerns. Strategies concerning how to develop a therapy for fear of delivery should take into account how to promote the women's motivation for therapy.30 Low motivation might mask undiagnosed and untreated depression. Such a depression could manifest as a puerperal one, and women with pregnancy‐ and delivery‐related fears as well as with previous depression are at high risk.8,10,20 In our study, as in earlier studies,10 depression was a constant finding. Clinical depression, when diagnosed, calls for treatment other than obstetric, certainly not surgical. In view of our study, fear of childbirth could be regarded as a sign of hidden depression, the diagnosis of and therapy for which would most likely improve the quality of the patient's and her partner's life.
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