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Psychological perspectives on fear of birth: heterogeneity, mechanisms and treatment
Mid Sweden University, Faculty of Human Sciences, Department of Psychology.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Although it is medically safe to give birth in most western countries, the vast majority of pregnant women experience some kind of anxiety, fear or worry in relation to their pregnancy or the upcoming childbirth. Most pregnant women find ways of coping with these issues but, for many, fear of birth is a significant source of distress during pregnancy, with negative consequences both when giving birth and in the postpartum period.

Previous research on fear of birth has for the most part had a medical perspective, investigating risk factors and consequences of this form of fear or anxiety, along with studies evaluating different forms of interventions. The general aim of this thesis was to approach fear of birth from a psychological perspective, by exploring the role of psychological factors in this form of fear, worry or anxiety.

Four studies are included in the thesis. The first study is a randomized controlled trial, in which we compared a guided Internet-delivered self-help program, based on cognitive behavior therapy (guided ICBT), with standard care (midwife led fear of birth specific counseling), for the treatment of fear of birth. Despite poor adherence to the guided ICBT, the results showed a similar reduction in fear levels during pregnancy in both groups, with lower levels of fear of birth in the guided ICBT group one year after birth. The second study is a narrative literature review. This study adopted a psychological perspective on the existing literature describing fear of birth, with a special focus on the specificity of this form of fear or anxiety, the pathways of fear acquisition, and the physiological, cognitive and behavioral aspects of fear of birth. Using systematic procedures for the literature search, inclusion and exclusion, 89 original research papers were included and summarized in the study. The aim of the third study was to explore possible heterogeneity among pregnant women reporting high levels of fear of birth. Comparisons between primiparous and multiparous women revealed that these groups were very similar in their levels of fear of birth as well as in the psychological variables investigated. Using a series of hierarchical and non-hierarchical cluster analyses, five possible subgroups based on psychological characteristics were identified, pointing to psychological heterogeneity among women fearing birth. In the fourth study, our aim was to take a first step in trying to identify psychological mechanisms relevant to the understanding of fear of birth. In this study, pain catastrophizing and intolerance of uncertainty were clear predictors of fear of birth, while parity was not.

Taken together, the results of the four studies included in this thesis indicate that fear of birth is a concept in need of further investigation, and that psychological perspectives could offer an important contribution to our understanding of this form of fear or anxiety. Women fearing birth seem to be a heterogeneous group, and psychological characteristics (e.g. pain catastrophizing, or catastrophizing in general, and intolerance of uncertainty) might be of greater importance than parity in both describing this diversity and understanding the development and maintenance of fear of birth. Treating fear of birth using guided ICBT can be challenging, and before introducing this form of treatment as an alternative, further refinement and evaluation of the methods are needed.

Abstract [sv]

Även om det medicinskt sett är förhållandevis säkert att föda barn i Sverige och andra västerländska länder, uppger de flesta gravida kvinnor att de känner en viss mån av rädsla, oro eller ångest kopplat till graviditeten eller den väntande förlossningen. De flesta kvinnor hittar ett sätt att hantera dessa upplevelser, men för många blir rädsla och oro inför förlossningen ständiga följeslagare under graviditeten.

Den befintliga forskningen om förlossningsrädsla har huvudsakligen utgått ifrån ett medicinskt perspektiv. Förlossningsrädsla har kopplats till olika riskfaktorer och till negativa konsekvenser i samband med förlossningen eller under den närmaste tiden därefter. Ett antal studier har också utvärderat olika interventioner för att förebygga eller behandla förlossningsrädsla. Huvudsyftet med denna avhandling har varit att undersöka förlossningsrädsla utifrån ett psykologisk perspektiv, och fokus har därmed legat på att studera psykologiska faktorers betydelse i relation till denna form av rädsla, oro eller ångest.

Avhandlingen innehåller fyra studier. Den första är en randomiserad kontrollerad studie, i vilken vi har jämfört effekterna av Internet-baserad kognitiv beteendeterapi med terapeutstöd och svensk standardvård (samtalsstöd med barnmorska) vid förlossningsrädsla. Trots lågt deltagande i den kognitiva beteendeterapin minskade graden av förlossningsrädsla på ett jämförbart sätt i båda behandlingsgrupperna under graviditeten, och ett år efter födseln var graden av rädsla något lägre i gruppen som erbjudits kognitiv beteendeterapi. Avhandlingens andra studie är en narrativ litteraturöversikt, som ger ett psykologiskt perspektiv på den befintliga forskningen om förlossningsrädsla. I studien sammanfattas fynd från 89 vetenskapliga artiklar, med ett särskilt fokus på resultat som kan ge oss ledtrådar om hur specifik denna form av rädsla är, rädslans olika inlärningsvägar, samt kognitiva, fysiologiska och beteendemässiga aspekter av förlossningsrädsla. Den tredje studien syftade till att undersöka potentiell heterogenitet bland gravida kvinnor med hög grad av förlossningsrädsla. Jämförelser mellan förstföderskor och omföderskor visade att dessa grupper var förhållandevis lika avseende grad av rädsla och psykologiska karakteristika. Istället identifierades fem möjliga subgrupper utifrån kvinnornas svarsmönster på psykologiska självskattningsinstrument. Resultaten från denna studie tyder på att skillnaderna mellan först- och omföderskor kanske inte är så stora i detta avseende, men att det kan finnas andra källor till psykologisk heterogenitet bland kvinnor med hög grad av förlossningsrädsla. Syftet med den fjärde studien var att ta ett första steg för att identifiera psykologiska mekanismer av betydelse för förståelsen för förlossningsrädsla. Höga självskattningar av smärtkatastrofiering och intolerans för osäkerhet predicerade hög grad av förlossningsrädsla. Däremot hade det ingen betydelse för graden av rädsla om deltagarna var först- eller omföderskor.

Sammantaget tyder resultaten från de fyra studierna på att förlossningsrädsla är ett fenomen som behöver studeras närmare, och att psykologiska perspektiv kan vara av betydelse för att öka vår förståelse för denna form av rädsla, ångest eller oro. Kvinnor med förlossningsrädsla tycks tillhöra en heterogen grupp, och psykologiska karakteristika såsom grad av smärtkatastrofiering eller intolerans för osäkerhet skulle kunna vara av större betydelse än paritet (d.v.s. om kvinnan är först- eller omföderska) för att beskriva denna mångfald och förstå hur förlossningsrädsla utvecklas och vidmakthålls. Att behandla förlossningsrädsla med Internet-baserad kognitiv beteendeterapi har sina utmaningar, och innan ett sådant behandlingsalternativ kan introduceras inom mödravården krävs fortsatt förfining och utvärdering av metoden.

Place, publisher, year, edition, pages
Sundsvall: Mid Sweden University , 2018. , p. 102
Series
Mid Sweden University doctoral thesis, ISSN 1652-893X ; 286
National Category
Applied Psychology
Identifiers
URN: urn:nbn:se:miun:diva-34359ISBN: 978-91-88527-63-9 (print)OAI: oai:DiVA.org:miun-34359DiVA, id: diva2:1246908
Public defence
2018-10-26, F234, Kunskapens väg 8, Östersund, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2018-09-11 Created: 2018-09-10 Last updated: 2018-09-11Bibliographically approved
List of papers
1. Comparing Internet-Based Cognitive Behavioral Therapy With Standard Care for Women With Fear of Birth: Randomized Controlled Trial.
Open this publication in new window or tab >>Comparing Internet-Based Cognitive Behavioral Therapy With Standard Care for Women With Fear of Birth: Randomized Controlled Trial.
Show others...
2018 (English)In: JMIR mental health, ISSN 2368-7959, Vol. 5, no 3, article id e10420Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Although many pregnant women report fear related to the approaching birth, no consensus exists on how fear of birth should be handled in clinical care.

OBJECTIVE: This randomized controlled trial aimed to compare the efficacy of a guided internet-based self-help program based on cognitive behavioral therapy (guided ICBT) with standard care on the levels of fear of birth in a sample of pregnant women reporting fear of birth.

METHODS: This nonblinded, multicenter randomized controlled trial with a parallel design was conducted at three study centers (hospitals) in Sweden. Recruitment commenced at the ultrasound screening examination during gestational weeks 17-20. The therapist-guided ICBT intervention was inspired by the Unified protocol for transdiagnostic treatment of emotional disorders and consisted of 8 treatment modules and 1 module for postpartum follow-up. The aim was to help participants observe and understand their fear of birth and find new ways of coping with difficult thoughts and emotions. Standard care was offered in the three different study regions. The primary outcome was self-assessed levels of fear of birth, measured using the Fear of Birth Scale.

RESULTS: We included 258 pregnant women reporting clinically significant levels of fear of birth (guided ICBT group, 127; standard care group, 131). Of the 127 women randomized to the guided ICBT group, 103 (81%) commenced treatment, 60 (47%) moved on to the second module, and only 13 (10%) finished ≥4 modules. The levels of fear of birth did not differ between the intervention groups postintervention. At 1-year postpartum follow-up, participants in the guided ICBT group exhibited significantly lower levels of fear of birth (U=3674.00, z=-1.97, P=.049, Cohen d=0.28, 95% CI -0.01 to 0.57). Using the linear mixed models analysis, an overall decrease in the levels of fear of birth over time was found (P≤ .001), along with a significant interaction between time and intervention, showing a larger reduction in fear of birth in the guided ICBT group over time (F1,192.538=4.96, P=.03).

CONCLUSIONS: Fear of birth decreased over time in both intervention groups; while the decrease was slightly larger in the guided ICBT group, the main effect of time alone, regardless of treatment allocation, was most evident. Poor treatment adherence to guided ICBT implies low feasibility and acceptance of this treatment.

TRIAL REGISTRATION: ClinicalTrials.gov NCT02306434; https://clinicaltrials.gov/ct2/show/NCT02306434 (Archived by WebCite at http://www.webcitation.org/70sj83qat).

Keywords
anxiety, cognitive behavioral therapy, fear of birth, internet-based, pregnancy
National Category
Applied Psychology
Identifiers
urn:nbn:se:miun:diva-34318 (URN)10.2196/10420 (DOI)000449378200001 ()30097422 (PubMedID)2-s2.0-85052907128 (Scopus ID)
Available from: 2018-08-31 Created: 2018-08-31 Last updated: 2019-03-27Bibliographically approved
2. Psychological perspectives on fear of childbirth
Open this publication in new window or tab >>Psychological perspectives on fear of childbirth
2016 (English)In: Journal of Anxiety Disorders, ISSN 0887-6185, E-ISSN 1873-7897, Vol. 44, p. 80-91Article in journal (Refereed) Published
Abstract [en]

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.

Keywords
Anxiety, Avoidance, Childbirth, Fear, Literature review, Pregnancy
National Category
Applied Psychology
Identifiers
urn:nbn:se:miun:diva-29298 (URN)10.1016/j.janxdis.2016.10.007 (DOI)000389732800009 ()27788373 (PubMedID)2-s2.0-84992498909 (Scopus ID)
Note

Available online 18 October 2016

Available from: 2016-11-15 Created: 2016-11-15 Last updated: 2018-09-10Bibliographically approved
3. Heterogeneity in childbirth related fear or anxiety
Open this publication in new window or tab >>Heterogeneity in childbirth related fear or anxiety
Show others...
2018 (English)In: Scandinavian Journal of Psychology, ISSN 0036-5564, E-ISSN 1467-9450, Vol. 59, no 6, p. 634-643Article in journal (Refereed) Published
Abstract [en]

Many pregnant women experience fear, worry or anxiety relating to the upcoming childbirth. The aim of this cross-sectional study was to investigate possible subgroups in a sample of 206 pregnant women (mean age 29.4 years), reporting fear of birth in mid-pregnancy. Comparisons were made between nulliparous and parous women. In a series of cluster analyses, validated psychological instruments were used to cluster women based on their psychological profiles. A five-cluster solution was suggested, with the clusters characterized by: overall low symptom load, general high symptom load, medium symptom load with high performance-based self-esteem, blood- and injection phobic anxiety, and specific anxiety symptoms. Nulliparous women were more likely to report clinically relevant levels of blood- and injection phobia (OR = 2.57, 95% CI 1.09–6.01), while parous women more often reported previous negative experiences in health care (OR 1.93, 95% CI 1.09–3.39) or previous trauma (OR 2.90, 95% CI 1.58–5.32). The results indicate that women reporting fear of birth are a heterogeneous group. In order to individualize treatment, psychological characteristics may be of greater importance than parity in identifying relevant subgroups. 

Keywords
anxiety, fear, childbirth, pregnancy, cluster analysis, blood- and injection phobia
National Category
Applied Psychology
Identifiers
urn:nbn:se:miun:diva-34320 (URN)10.1111/sjop.12481 (DOI)000449851300009 ()30176051 (PubMedID)2-s2.0-85053239503 (Scopus ID)
Available from: 2018-08-31 Created: 2018-08-31 Last updated: 2019-03-27Bibliographically approved
4. Potential mechanisms in fear of birth: The role of pain catastrophizing and intolerance of uncertainty.
Open this publication in new window or tab >>Potential mechanisms in fear of birth: The role of pain catastrophizing and intolerance of uncertainty.
2019 (English)In: Birth, ISSN 0730-7659, E-ISSN 1523-536X, Vol. 46, no 1, p. 61-68Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Although many pregnant women experience fear, worry, or anxiety relating to the upcoming birth, little is known regarding the psychological mechanisms contributing to these experiences. In this study, we wanted to take a first step in trying to identify mechanisms of potential interest. The objective of this cross-sectional study was thus to investigate pain catastrophizing, intolerance of uncertainty, positive worry beliefs, and cognitive avoidance as potential mechanisms predicting fear of birth among pregnant women.

METHODS: A sample of 499 pregnant women, recruited in antenatal health care settings in 2 Swedish regions, completed the Fear of Birth Scale, along with measurements of the mechanisms of interest. Linear and logistic hierarchical regression analyses were used to investigate the extent to which pain catastrophizing, intolerance of uncertainty, positive worry beliefs, and cognitive avoidance predicted fear of birth, both as a continuous and a dichotomous measure.

RESULTS: Logistic regression analysis showed high levels of pain catastrophizing and intolerance of uncertainty to be the best predictors of fear of birth, OR 3.49 (95% CI 2.17-5.61) and OR 3.25 (95% CI 2.00-5.27), respectively. Positive beliefs about worry and cognitive avoidance were both correlated with fear of birth as a continuous measure, but did not contribute to the logistic regression model.

CONCLUSIONS: Pain catastrophizing and intolerance of uncertainty were the most evident predictors of fear of birth. Although preliminary, the findings suggest that interventions targeting catastrophic cognitions and intolerance of uncertainty might be relevant to psychological treatment for fear, worry, or anxiety relating to giving birth.

Keywords
fear of birth, intolerance of uncertainty, pain catastrophizing
National Category
Applied Psychology
Identifiers
urn:nbn:se:miun:diva-34319 (URN)10.1111/birt.12368 (DOI)000459794300007 ()29954044 (PubMedID)2-s2.0-85061577739 (Scopus ID)
Available from: 2018-08-31 Created: 2018-08-31 Last updated: 2019-08-07Bibliographically approved

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