Pregnancy and childbirth are physiological events of emotional and social significance in women's lives. Inevitably unpredictable, childbirth should be a positive experience for women with the lowest risk of adverse outcomes.1 However, since the 1980s, there is increasing evidence that fear of childbirth impacts the health and well-being of a significant number of women of reproductive age.2,3
In literature, there is no clear operational definition for fear of childbirth.3 The heterogeneity, and even possible inconsistencies in different existing tools to evaluate and measure fear of childbirth, can cause problems in defining this concept and difficulties in prevalence rate comparison across practice and research.2,3 Currently, the most widely used measurement tool for fear of childbirth in pregnant women is the Wijma Delivery Expectancy Questionnaire (WDEQ-A); however, there is a growing discussion of simpler, more culturally transferable tools providing better identification of fearful women.2 Studies have found that the prevalence of intense fear of childbirth, when measured using the same instrument, ranges from 4.8% in Australia4 to 6.3% in Belgium and 14.8% in Sweden.2
Current evidence shows that although the fear is multi-dimensional, previous negative birth experience or operative birth is the strongest predictor.5 Fear of childbirth negatively affects women's health and well-being before and during pregnancy, and the experience of birth.6,7 It is associated with an increase in adverse effects on obstetric outcomes,5,7 such as increased elective cesarean delivery rates8 and postpartum mental disorders.5,9
Fear of childbirth is a field of interest in the scientific community. In recent years, international research has focused on the development, implementation, and evaluation of interventions to reduce fear of childbirth.9-13 Examining the use of interventions to reduce fear of childbirth in pregnant women supports the commitment to improve maternal and obstetric health care, and ultimately reproductive health worldwide.
These interventions aim to address the complex nature of the issues surrounding care practice to ensure better health outcomes for women, create thriving families, and prioritize person-centered health and well-being—not just the prevention of death and morbidity—according to evidence-based practice and the human rights–based approach.14-17 Some of these initiatives highlight the concepts of positive pregnancy15 and childbirth experience16 as key aspects of women-centered health care and their families.
Women want a positive pregnancy experience through antenatal care. In this regard, the World Health Organization recommendations on antenatal care for a positive pregnancy experience include a comprehensive guideline on routine antenatal care for women and adolescent girls. Among these recommendations, midwifery-led continuity of care has been promoted as an effective approach to maternal and newborn care.15 According to the International Confederation of Midwives (ICM):
The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife's own responsibility and to provide care for the newborn and the infant. … The midwife has an important task in health counselling and education…18(p.1)
This overall definition is comprehensible and appropriate, and will guide this review, which seeks to broaden the knowledge of midwife interventions in the context of fear.
In midwife-led continuity of care models, a woman receives care from the same midwife (caseload midwifery) or small groups of known midwives (team midwifery); is supported throughout the antenatal, intrapartum, and postnatal period to facilitate healthy pregnancy and childbirth; and is exposed to healthy parenting practices through one-on-one support.15,16,19,20
For the ICM, midwifery-led care is the most appropriate model of care for childbearing women, combining safe and high-quality care through the efficient use of resources and positive results.19-21 This model requires midwifery, and more specifically midwives, to situate themselves as part of a team within a functional and conducive health system with appropriately skilled and competent health workforce.22 In the context of discussions on the global consensus on the most qualified caregivers for women's health care, the ICM recognizes midwives as autonomous professionals of choice for pregnant women in all regions of the world.18,21
Midwives are the primary caregiver and expert in normal childbirth.15,21,23 The promotion of normal childbirth is included in the ICM scope of practice; therefore, midwives should be competent in all means of supporting the physiology of childbirth.23 Due to their crucial role in antenatal care for pregnant women,15 midwives can facilitate the process of reducing the fear of childbirth and/or adopting positive feelings about normal childbirth. Fear of childbirth indicates the need for midwives to intervene with women to help them reshape their expectations and confidence levels, improve their knowledge about labor and childbirth, and empower them to make sound decisions, assuming themselves as key strategies to promote normal birth and improve the quality of women's reproductive health.
Today, the context of midwifery practice is constantly changing because of social transformations, scientific and technological advances in maternal and obstetric health, changes in world demographics leading to increasingly fluctuating populations, women's self-expectations of pregnancy and childbirth experiences, and a paradigm shift in health care that puts the person at the center of care. In light of the need for adaptation to these emerging challenges, the scope of midwife care will necessarily depend on access to current knowledge and acquisition of specific skills, whereby fear of childbirth is an emerging field.
Some studies have reported positive results of interventions on fear of childbirth, and their use by health professionals is encouraged.9-13 Interventions to reduce the fear of childbirth have been tested and applied in different contexts and phases of the perinatal period, with different protocols using different techniques and/or strategies implemented by multidisciplinary teams (with no midwife included or at least one midwife in the team) and midwife teams.9-12
There are already a considerable number of systematic reviews on fear of childbirth.2,3,5,24,25 Although some current reviews focused on the effectiveness of interventions to reduce the fear of childbirth,24,25 the type of health professional was not clearly defined in the inclusion criteria. To date, there have been no reviews that present and evaluate the evidence on the use of interventions to reduce the fear of childbirth in pregnant women, led and implemented by midwives, during the antenatal period. Therefore, there is little knowledge of what these interventions are and how they work. The literature does not clarify the role of the midwife in leading and implementing the intervention. Today, midwives face the need to implement an appropriate model of midwifery care to respond to the challenge of fear of childbirth. However, there has been no mapping of activities and/or strategies used by midwives for pregnant women with fear of childbirth, creating a need to map the evidence in order to establish the current extent, scope, and nature of this emerging field of research.
Furthermore, the information about the abovementioned interventions, and their methods and/or strategies, application contexts, and subgroups of pregnant women, are dispersed in the literature. This precludes the formulation of precise questions about the effectiveness of particular midwife interventions for reducing fear of childbirth. Without this clarification, it is not possible to proceed to a systematic review on this topic. Consequently, important questions about the nature of the evidence in this area need to be answered before effectiveness can be assessed.
By providing a detailed description and summary of the available information, this scoping review will contribute to the dissemination of research results and also identify possible gaps in knowledge, providing conclusions about the overall state of research activity in this area and the need for future research.26
The scoping review will be guided by the methodology proposed by JBI for scoping reviews26 and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes extension for Scoping Reviews (PRISMA-ScR) checklist.27
A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports was conducted. No current or active scoping reviews that map the evidence on this topic were found. However, some systematic reviews (both published24,25 and ongoing28) have evaluated interventions that reduce the fear of childbirth. The review by Hosseini et al.,24 published in 2018, examined the effects of interventions for reducing fear of childbirth. The authors included any type of intervention during pregnancy and/or postpartum period. Striebich et al.25 identified and reviewed studies examining the effects of an intervention for relief of severe fear of childbirth in pregnancy and their underlying conceptual foundation (regardless of staff members). Although, these two systematic reviews provide insights into interventions to reduce fear of childbirth, their strict inclusion and exclusion criteria do not address the broader criteria of this current scoping review, mainly because they include interventions led, implemented, and evaluated by different health professionals. They did not provide a systematic mapping of all evidence about midwife interventions in pregnant women with fear of childbirth. Hence, these reviews are different from those scoping review, mainly in relation to the type of health care providers involved, and evaluation of outcomes (primary and secondary) after the intervention.
It is indisputable that new knowledge about midwife interventions to reduce the fear of childbirth in pregnant women can be extracted and incorporated in evidence-based practice. Therefore, the objective of this scoping review is to map and analyze published and unpublished research on midwife interventions to reduce fear of childbirth in pregnant women.
- i) What midwife interventions have been led and implemented to reduce fear of childbirth in pregnant women?
- ii) What are the characteristics of midwife interventions to reduce fear of childbirth in pregnant women (e.g. type of the intervention, theoretical concept, single and/or combined activity, duration, frequency, number of sessions)?
This scoping review will consider all studies that include a midwife (or midwifery teams) who works either independently or within a multidisciplinary team, with both cases explicitly identifying a midwife intervention to reduce fear of childbirth in pregnant women. Studies addressing interventions, techniques, and/or strategies to reduce the fear of childbirth in pregnant women conducted only by other health professionals will be excluded.
Professionals’ titles vary according to different countries, as well as the legislation related to the profession in each country. Therefore, this review will consider all professionals with the title “midwife,” based on the universal standard underlying the definition of ICM:
A midwife is a person who has successfully completed a midwifery education programme that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education and is recognized in the country where it is located; who has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery and use the title ‘midwife’; and who demonstrates competency in the practice of midwifery.18(p.1)
This review will include all studies that explore midwife interventions led and implemented to reduce fear of childbirth. All studies that do not have this as the main objective will be excluded, as will studies in which reduction of fear of childbirth is not clearly defined as a primary outcome in the research design. The review will include any type of intervention, as long as it falls within the autonomous competencies of the midwives provided by the ICM's Essential Competencies for Basic Midwifery Practice29 and the ICM Global Standards for Midwifery Regulation.30
This scoping review will consider all research studies that focus on pregnant women diagnosed with fear of childbirth and that have integrated midwife interventions. The diagnosis of fear of childbirth will be determined by means of validated self-reported questionnaires/tools or diagnostic interviews. If the study does not mention how the diagnosis of fear of childbirth has been made, it will be excluded. The assessment or measurement of fear of childbirth may be at any particular time of the pregnancy. Studies addressing the fear of childbirth in couples or men will be excluded.
This scoping review will consider studies that integrated interventions led and implemented by midwives during the antenatal period. Studies that include interventions to reduce fear of childbirth before pregnancy or during the intrapartum or postpartum period will be excluded.
All health care settings possible for midwifery practice will be considered: obstetric units/maternity units inside hospitals, freestanding midwifery units, alongside midwifery units, and home births. All geographical and cultural contexts will be included.
The context of the proposed scoping review will use definitions developed by National Institute for Health and Care Excellence,31 National Collaborating Centre for Women's and Children's Health,32 and Rowe33 for guidance in the inclusion of studies. A glossary of terms is shown in Table 1.
Type of studies
This scoping review will consider quantitative, qualitative, and mixed methods primary studies for inclusion. It will consider both experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. In addition, analytical observational studies, including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies, will be considered for inclusion. It will also consider descriptive observational study designs, including case series, individual case reports, and descriptive cross-sectional studies for inclusion.
This review will consider studies that focus on qualitative data, including designs such as phenomenology, grounded theory, ethnography, action research, and feminist research.
Systematic reviews that meet the inclusion criteria and text and opinion papers will also be considered for inclusion. Duplicates articles, articles without an abstract, and articles with full text unavailable will be excluded. Articles published in English, Portuguese, and Spanish will be included. Articles published from 1981 (year of publication of the first article on a study on fear of childbirth) to the present will be included.
The proposed review will be conducted in accordance with JBI methodology for scoping reviews.26
A three-phase approach will be implemented in order to locate both published and unpublished studies.26,34 An initial limited search of MEDLINE and CINAHL databases will be undertaken, using keywords/text words and indexed terms (MeSH descriptors and DeCS descriptors; see Appendix I) to identify articles on the topic (first phase). The keywords/text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles will be used to develop a full search strategy (second phase). A full search strategy for Scopus database is detailed in Appendix II. The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of all studies selected for inclusion will be screened for additional studies (third phase).
The databases to be searched include MEDLINE, CINAHL, PsycINFO, Scopus, Embase, Web of Science, SciELO (Scientific Electronic Library Online), Cochrane Library (including Cochrane Database of Systematic Reviews, Cochrane Methodology Register, and Cochrane Central Register of Controlled Trials), MedicLatina, Academic Search Complete, ERIC (Education Resources Information Center), and Psychology and Behavioral Sciences Collection.
Sources of unpublished studies and gray literature to be searched include Repositório Científico de Acesso Aberto de Portugal (Portugal), ProQuest Dissertations and Theses, British Library EThOS (Electronic Thesis Online Service), OvidSP Resource Center, Banco de Teses da CAPES (Brazil), and OpenGrey.
Following the search, all identified records will be collated and uploaded to Mendeley (Mendeley Ltd., Elsevier, Netherlands), and duplicates removed. Titles and abstracts will then be screened by two reviewers, independently, to assess eligibility according to the inclusion criteria for the review. Citations of eligible studies retrieved in full will be imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).26 The full texts of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text papers that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.26,35
Data will be extracted from papers included in the scoping review using a data extraction tool developed by the reviewers. The data extracted will include specific details about the participants, concept, context, methods and study details. A draft of the extraction tool is provided (see Appendix III). This draft is a working document that will be modified and revised as necessary during the process of extracting data from each included paper. Modifications will be detailed in the full scoping review report. Two reviewers will extract data independently. Any disagreements that arise between the two reviewers will be resolved through discussion or with a third reviewer, as needed. Authors of papers will be contacted to request missing or additional data, where required.
The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objectives and scope of this scoping review. Data that are presented in tables will reflect the information collected using a data extraction tool. For review question 1, this will include: i) the authors, year of publication, country (where the study was conducted); ii) study details (e.g. aims, study design, study population, sample size, diagnosis); iii) study setting; and iv) type of midwife intervention (see Appendix IV).
For review question 2, a draft form has been developed that includes detailed key information about each midwife intervention (see Appendix V). A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the review questions.
Francisco Vieira, who provided support in the development of the search strategy.
Appendix I: Search terms
Appendix II: Search strategy
Search conducted in February 2019
Limited to: 01-01-1981–2019; English, Portuguese, and Spanish
Appendix III: Data extraction instrument
Appendix IV: Data presentation template: question 1
What midwife interventions have been led and implemented to reduce fear of childbirth in pregnant women?
Appendix V: Data presentation template: question 2
What are the characteristics of midwife interventions to reduce fear of childbirth in pregnant women?
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