Obstetrics & Gynecology:
Fear of Childbirth and Pregnancy-Related Anxiety in Women Conceiving With Assisted Reproduction
Poikkeus, P MD1; Saisto, T MD, PhD2; Unkila-Kallio, L MD, PhD1; Punamaki, R L. PhD3; Repokari, L MD4; Vilska, S MD5; Tiitinen, A MD, PhD1; Tulppala, M MD, PhD1
From the 1Department of Obstetrics and Gynecology, Helsinki University Central Hospital; 2Department of Obstetrics and Gynecology, Jorvi Hospital, Helsinki University Central Hospital; 3Department of Psychology, University of Tampere; 4Hospital for Children and Adolescents, Helsinki University Central Hospital; and 5Infertility Clinic, the Family Federation of Finland, Helsinki, Finland.
Corresponding author: Dr. Piia Poikkeus, HYKS-instituutti huone 3009/Terkko, Haartmaninkatu 4, 00290 Helsinki, Finland; e-mail email@example.com.
This study was supported by the Päivikki and Sakari Sohlberg Foundation, by the Clinical Graduate School, Pediatrics and Obstetrics/Gynecology, University of Helsinki, and by Research Funds from Helsinki University Central Hospital. Organon, Finland and Serono, Finland have also given financial support to our work.
The authors thank Vilho Hiilesmaa, MD, PhD, for statistical advice.
OBJECTIVE: To compare the prevalence and predictors of severe fear of childbirth and pregnancy-related anxiety in groups of assisted reproduction treatment (ART) and spontaneously conceiving women with singleton pregnancies.
METHODS: The ART group (n = 367, nulliparous 260) represented a cohort from five Finnish infertility clinics in 1999. The control group (n = 379, nulliparous 135) was enrolled in this study by consecutive sampling the same year. Fear of childbirth was assessed by means of the revised version of the Fear-of-Childbirth Questionnaire and pregnancy-related anxiety by means of the Pregnancy Anxiety Scale at gestational week 20 ± 3.2 (mean±standard deviation).
RESULTS: The frequency of severe fear of childbirth and anxiety (classified as total scores in the 90th percentile or higher in the revised Fear of Childbirth Questionnaire and Pregnancy Anxiety Scale) did not differ between the groups. Nulliparity was associated with more frequent severe anxiety only in the controls. In nulliparous participants, a partnership of more than 5 years decreased the risk of severe fear of childbirth (odds ratio 0.3, 95% confidence interval 0.2–0.7). In the nulliparous ART group, a long duration of infertility (7 or more years) increased the risk of severe fear of childbirth (odds ratio 4.4, 95% confidence interval 1.2–16.9).
CONCLUSION: Women conceiving after ART do not experience severe fear of childbirth or pregnancy-related axiety more often than spontaneously conceiving controls. However, a long duration of infertility is an independent risk factor regarding severe fear of childbirth.
LEVEL OF EVIDENCE: II-2
During pregnancy a woman prepares mentally for permanent life changes and new responsibilities after the birth of the infant. Ambivalent feelings are a normal part of this process, but for some women, these feelings intensify, leading to fear of childbirth and pregnancy-related anxiety. One in five pregnant women experiences moderate fear of childbirth, and 6–13% of pregnant women experience severe, disabling fear of childbirth.1–4 Fear of childbirth results in an increased number of visits to obstetricians after somatic symptoms and in frequent requests for cesarean delivery.5–6 Previous nonviable pregnancies and complicated childbirth are connected to fear of childbirth, but a woman's traumatic life events, depression, general anxiety, low self-esteem, and dissatisfaction with the partnership also contribute strongly.3,5–8
In earlier studies among unselected pregnant women, previous infertility has not been associated with severe fear.5,9,10 Nevertheless, these results are based on relatively small subgroups of previously infertile participants, and they may be insensitive to the duration of infertility and to treatment procedures. Infertility investigations and the process of going through assisted reproductive technology (ART) are stressful, and the major predisposing factors of fear of childbirth—depression and anxiety—are also present in 20–40% of infertile women.11–13 For the majority of women, the symptoms of depression and anxiety become resolved after successful treatment, but for up to 20% of infertile women, the emotional burden of infertility persists even after giving birth.14 Furthermore, the results of two studies show that, although they have a similar prevalence of general anxiety as controls, women conceiving after ART are more prone to anxiety over loss of their pregnancy.15,16 Pregnancy-related anxiety, on the other hand, is significantly associated with fear of childbirth in unselected low-risk pregnant women.8 Altogether, because of the psychological burden of ART and increased pregnancy-specific anxiety, women conceiving after ART might be especially vulnerable to fear of childbirth.
The aim of this study was to compare the prevalence of severe fear of childbirth and pregnancy-related anxiety in second trimester in groups of ART and spontaneously conceiving women with singleton pregnancies. We compared both the whole groups and parity-stratified groups. Second, we evaluated demographic and obstetric predictors of severe fear of childbirth and pregnancy-related anxiety in nulliparous participants. Finally, we analyzed the role of the etiology and duration of infertility and the number and the type of ART in predicting severe fear of childbirth and severe pregnancy-related anxiety in the nulliparous ART group.
MATERIALS AND METHODS
The studied women took part in a larger, prospective and longitudinal controlled study on somatic and mental health of ART families. The ART group was a cohort of women conceiving after ART from the infertility clinics of Helsinki University Central Hospital, the Family Federation of Finland (Helsinki, Oulu and Turku), and the Deaconess Institute (Helsinki) in 1999. All volunteering Finnish-speaking women with confirmed viable singleton pregnancy after either fresh or frozen in vitro fertilization or intracytoplasmic sperm injection with their own gametes were recruited to this study.
The Finnish-speaking, spontaneously conceiving control women were recruited by consecutive sampling during their appointment for a screening ultrasonographic scan at gestational weeks 16–18 at Helsinki University Central Hospital the same year. Exclusion criteria for the control women were previous infertility, infertility treatment, and maternal age less than 25 years. All participants received oral and written information about the study and gave written informed consent voluntarily. The clinics' Ethics Committees approved this study.
Collection of the data has been reported previously.17 In short, the participants completed a set of questionnaires at a mean of 20 (standard deviation [SD] ± 3.2) weeks of gestation. In addition, the recruiting infertility doctor or the research nurse collected information on preceding infertility treatments from clinics' patient registries and on the medical and obstetric histories of the participants by means of structured questions.
Fear of childbirth was assessed by means of the revised version of the Fear-of-Childbirth Questionnaire (Cronbach's alpha 0.72). The original Questionnaire18 was revised to suit a Finnish population by Saisto.8,19 The revised Fear-of-Childbirth Questionnaire consisted of 11 dichotomous questions, and affirmative answers indicated fear. Pregnancy-related anxiety was assessed by means of the Pregnancy Anxiety Scale (Cronbach's alpha 0.80) revised by Levin.20 This has shown high reliability, including in Finnish samples.8,19 The anxiety scale covered three dimensions of pregnancy-related anxiety: anxiety about being pregnant, anxiety about giving birth, and anxiety about hospitalization. It included 10 five-scale questions (one = not at all, five = a lot). Total scores equal to or higher than the 90th percentile in the revised Fear-of-Childbirth Questionnaire (total scores 6 or higher) and Pregnancy Anxiety Scale (total scores 30 or higher) were considered to show “severe fear” and “severe pregnancy-related anxiety,” respectively.8 With 80% power, .05 two-sided significance, we could detect a difference of 7% in the prevalence of severe fear of childbirth and pregnancy-related anxiety between the ART and control groups. Total scores in the revised Fear-of-Childbirth Questionnaire and Pregnancy Anxiety Scale were highly correlated (r = 0.73, P = .001).
The participants were also asked to report the presence or absence of somatic symptoms (none, hyperemesis, bleeding, other not specified) in structured dichotomous questions.
The statistical software package SPSS 12.0.1 (SPSS Inc., Chicago, IL) was used for all data analyses. Continuous variables were analyzed by means of Student t test. Categorical variables were analyzed by means of Fisher exact test. A P value less than .05 was regarded as statistically significant. Two separate adjusted multiple logistic regression analyses were run regarding the nulliparous participants. First, the impact of demographic factors such as age (20–29, 30–34, 35–44 years), educational level (high professional, low professional, skilled worker, unskilled worker), type (married or cohabiting) and duration of partnership (less than 5, 5–10, more than 10 years), and obstetric factors (previous nonviable pregnancies and somatic symptoms in the present pregnancy) in predicting severe fear of childbirth and severe pregnancy-related anxiety was analyzed. Second, age-adjusted infertility and treatment-related predictors (etiology and duration of infertility, and ordinal and type of treatment) of severe fear of childbirth and severe pregnancy-related anxiety were investigated in the nulliparous ART group. We also analyzed whether clinic-to-clinic variation existed in our material by including infertility clinic as a predictor to the above-explained logistic regression model.
Three hundred sixty-seven (92.4%) out of 397 initially recruited women conceiving after ART and 379 (81.7%) out of 464 control women took part in the study (P < .001). The studied pregnancies represent 367 of 412 (89.1%, ART group) and 379 of 2,187 (17%, control group) of eligible pregnancies from the recruiting clinics in 1999.
The demographic data, obstetric history, and somatic symptoms are presented first among all participants and then among nulliparous women in Table 1. The partnership had lasted longer (mean of two years longer) and marriage was more frequent in the ART group than in the control group, irrespective of parity. Among nulliparous participants, the control women were slightly older and of higher educational level than the ART women. Previous pregnancies and deliveries were more frequent in the control women than in the ART women, with the exception of more numerous previous ectopic pregnancies in the ART group. The prevalence of somatic complaints differed only in more frequent “other not specified” somatic complaints in the control group than in the ART group. Infertility and ART-related characteristics are given in Table 2.
Severe fear of childbirth and pregnancy-related anxiety was expressed in equal proportions in the ART and the control groups (Table 3). Also, the medians of revised Fear-of-Childbirth Questionnaire (2.0) and Pregnancy Anxiety Scale (20.0) scores were similar between the groups. Comparison of pregnancy-, delivery- and hospitalization-specific Pregnancy Anxiety Scale questions did not reveal any differences between the ART and the control group.
Severe fear of childbirth was more frequent in the nulliparous women (53 of 395 [13.4%]) than in the parous women (29 of 351 [8.3%]); P = .03. Nulliparous women reported also more often severe pregnancy-related anxiety (57 of 395 [14.4%]) than the parous participants (27 of 351 [7.7%]); P = .004. The association between parity and fear of childbirth and pregnancy-related anxiety was different in the study groups. In the ART group, the prevalence of severe fear of childbirth and pregnancy-related anxiety did not differ between nulliparous and parous women. Instead, the nulliparous control women showed more frequent severe pregnancy-related anxiety than parous controls (Table 3).
The demographic and obstetric predictors of severe fear of childbirth and severe pregnancy-related anxiety were investigated in multiple logistic regression analysis in nulliparous participants (Table 4). More than 5 years of partnership decreased the risk of severe fear of childbirth (odds ratio [OR] 0.3, 95% confidence interval [CI] 0.2–0.7), whereas women's age, educational level, history of nonviable pregnancy, or presence of any somatic symptom in this pregnancy did not affect the risks. None of the studied factors affected the risk of pregnancy-related anxiety.
Infertility and treatment-related factors in predicting severe fear and anxiety were analyzed among nulliparous ART women in a separate adjusted multiple logistic regression analysis (Table 5). Long duration of infertility (7 or more years) increased the risk of severe fear of childbirth (OR 4.4, 95% CI 1.2–16.9). Numerous previous IVF attempts (four or more), on the other hand, decreased the risk of severe fear (OR 0.06, 95% CI 0.005–0.7). The etiology of infertility and treatment type did not affect the risk of either severe fear of childbirth or severe pregnancy-related anxiety. The inclusion of infertility clinic to the logistic regression model did not affect the before-explained results and was not associated independently with severe fear of childbirth and pregnancy-related anxiety.
The number of annual ART cycles is increasing in Europe and the United States, and understanding both the psychological and somatic consequences of these treatments is needed.21–22 We hypothesized that cumulative stress and previous disappointments after infertility investigations and treatments could promote fear of childbirth and pregnancy-related anxiety in women conceiving after ART. However, according to our results, infertility and ART do not expose a woman to an increased risk of fear of childbirth, supporting the results of earlier case-control studies.8–10 Only women with a long period of infertility appear to be a vulnerable group in terms of severe fear of childbirth. Our results further show that women conceiving after ART are not more anxious about the pregnancy than the controls, in contrast to previous results.15,16 Interestingly, nulliparity was associated with more prevalent severe pregnancy-related anxiety in the control group, but not in the ART group. More frequent fear of childbirth among nulliparous women has been reported previously.23–26
We analyzed fear of childbirth and pregnancy-related anxiety at previously used assessment time and by means of reliable and valid methods.8,19 Nearly 90% of eligible pregnant ART women took part in this study, and in terms of age and parity our ART group is representative compared with both national and international ART registers.27,28 The medians of total revised Fear-of-Childbirth Questionnaire and Pregnancy Anxiety Scale scores were relatively low and comparable with those among unselected Finnish pregnant women.8 Comparison of our scores with results from international studies is unfortunately not possible because the content of fear-of-childbirth questionnaires, and the assessment time, vary from one study to another. Our assessment of fear of childbirth and pregnancy-related anxiety at the second trimester is clinically reasonable because it leaves enough time for therapeutic interventions before delivery. However, our results from the 20th gestational week may be influenced by more pronounced general well-being than results from the other trimesters.29–33
A couple of limitations of our study deserve mention. First, our sample size was not sufficient to detect the relatively small differences in prevalence of severe fear of childbirth and pregnancy-related anxiety as noticed in this material with high power. Indeed our study's power to detect the observed differences in prevalence of severe fear of childbirth and severe pregnancy-related anxiety was 4% and 16% percent, respectively (at the .05 significance level). Nevertheless, the observed differences between the groups hardly bear a clinical significance when differentiating women with severe fear of childbirth or pregnancy-related anxiety and women without them. Second, we did not include depression, general anxiety, or satisfaction with partnership (the most important psychological contributors regarding fear of childbirth and pregnancy-related anxiety) in this study. Our decision to limit our analyses to the demographic and obstetric predictors of fear of childbirth and pregnancy-related anxiety corresponds to the clinical setting where usually only these factors are easily accessible. A clinician should still keep in mind the possibility of underlying and coexisting psychological problems in women showing fear of childbirth. Third, the results of several studies have indicated that previous operative delivery contributes strongly to the experience of fear and anxiousness in a subsequent pregnancy.5,34–37 Unfortunately, we could not control for previous delivery experience owing to deficient obstetric histories of the participants. We therefore restricted the logistic regression analyses of possible predictors of fear of childbirth and pregnancy-related anxiety to nulliparous participants.
The only significant demographic predictor of fear of childbirth in this study was the duration of partnership: a 5- to 10-year partnership decreased the risk of severe fear of childbirth. The observed protective role of a relatively long partnership regarding fear of childbirth has been noticed before and probably highlights the importance of the psychosocial support provided by a satisfactory partnership during pregnancy.8,28 Bringing this finding to the other extreme, underlying partnership problems may exacerbate severe fear of childbirth and should be actively taken under discussion in the maternity care with women fearing childbirth. The observed protective role of a relatively long partnership regarding fear of childbirth could also explain the different impact of parity in the groups, as the partnerships were significantly longer in the ART than in the control group irrespective of the parity.
The long partnership may, however, not diminish the trauma of a long preceding infertility. Our results indicate that women with a long history of infertility are at an increased risk of severe fear of childbirth, which corresponds well to our study's hypothesis. Based on our results, a special support during pregnancy should be provided to women with a long period of infertility. Interestingly, numerous preceding assisted reproductive treatments (more than four) decreased the risk of severe fear of childbirth. The former suggests that repeating ART does not cause an additional psychological stress and fear of childbirth to an infertile woman.
To conclude, the similarly reported fear of childbirth and pregnancy-related anxiety to the controls could be a sign of well-dealt crisis of infertility and good psychological support in the ART group. The observed protective role of a long partnership emphasizes the need to consider fear of childbirth as a problem involving both partners and influencing their future relationship with the infant.
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