Is it Necessary to Evaluate Fear of Childbirth in Pregnant Women? A Scoping Review

Imakawa, Cibele Santini de Oliveira; Nadai, Mariane Nunes de; Reis, Monica; Quintana, Silvana Maria; Moises, Elaine Christine Dantas

doi:10.1055/s-0042-1751062

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Brasil

Revista Brasileira de Ginecologia e Obstetrícia

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Review Article • Rev Bras Ginecol Obstet. 44 (07) • July 2022 • https://doi.org/10.1055/s-0042-1751062 copy

Is it Necessary to Evaluate Fear of Childbirth in Pregnant Women? A Scoping Review

É necessário avaliar o medo do parto em gestantes? Uma revisão de escopo

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To review concepts, definitions, and findings about fear of childbirth (FOC).

Methods

A bibliographic review was carried out through the main scientific databases in 2020.

Results

All 32 articles considered potentially relevant were analyzed. A recent study suggests that the global prevalence of FOC can reach up to 14%. Factors such as parity, gestational age, previous birth experience, age and nationality of the woman seem to influence FOC.

Conclusion

Fear of childbirth could be related to an increased risk of adverse obstetric outcomes such as maternal request for cesarean delivery, preterm birth, prolonged labor, postpartum depression, and post-traumatic stress. These evidence highlight the importance of the discussion regarding this topic.

Keywords
fear; childbirth; obstetric labor; pregnant; delivery

Title	Country, year	Outlining/ number of patients	Interventions	Outcomes/Results
Psychological perspectives on fear of childbirth¹1 Rondung E, Thomtén J, Sundin Ö. Psychological perspectives on fear of childbirth. J Anxiety Disord 2016; 44: 80-91 DOI: 10.1016/j.janxdis.2016.10.007. https://doi.org/10.1016/j.janxdis.2016.1...	Sweden, 2016	Narrative review, 86 studies	N/A	To examine the literature on FOC from a psychological perspective
Definitions, measurements and prevalence of fear of childbirth: a systematic review.²2 Nilsson C, Hessman E, Sjöblom H, Dencker A, Jangsten E, Mollberg M. et al. Definitions, measurements and prevalence of fear of childbirth: a systematic review. BMC Pregnancy Childbirth 2018; 18 (01) 28 DOI: 10.1186/s12884-018-1659-7. https://doi.org/10.1186/s12884-018-1659-...	Sweden, 2018	Systematic review, 24 studies	N/A	To summarize published research on the prevalence of FOC in childbearing women and how it is defined and measured during pregnancy and the postpartum period
Potential mechanisms in fear of birth: The role of pain catastrophizing and intolerance of uncertainty.³3 Rondung E, Ekdahl J, Sundin Ö. Potential mechanisms in fear of birth: The role of pain catastrophizing and intolerance of uncertainty. Birth 2019; 46 (01) 61-68 DOI: 10.1111/birt.12368. https://doi.org/10.1111/birt.12368...	Sweden, 2019	Cross-sectional study, 499 women, FOBS	N/A	To investigate pain catastrophizing, intolerance of uncertainty, positive worry beliefs, and cognitive avoidance as potential mechanisms predicting FOC among pregnant women. / Pain catastrophizing and intolerance of uncertainty were the most evident predictors of FOC.
Worldwide prevalence of tocophobia in pregnant women: systematic review and meta-analysis.⁴4 O'Connell MA, Leahy-Warren P, Khashan AS, Kenny LC, O'Neill SM. Worldwide prevalence of tocophobia in pregnant women: systematic review and meta-analysis. Acta Obstet Gynecol Scand 2017; 96 (08) 907-920 DOI: 10.1111/aogs.13138. https://doi.org/10.1111/aogs.13138...	Ireland, 2017	Systematic review, 33 studies	N/A	To determine the overall pooled prevalence of tokophobia
Fear of childbirth: a neglected dilemma.⁵5 Saisto T, Halmesmäki E. Fear of childbirth: a neglected dilemma. Acta Obstet Gynecol Scand 2003; 82 (03) 201-208	Finland, 2003	Review	N/A	Preliminary Swedish and Finnish reports demonstrated the results of treatment during pregnancy, when more than half of the women withdrew their request after being able to discuss their anxiety and fear, and vaginal deliveries after treatment were successful.
Fear of childbirth in nulliparous and multiparous women: a population-based analysis of all singleton births in Finland in 1997-2010.⁶6 Räisänen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. Fear of childbirth in nulliparous and multiparous women: a population-based analysis of all singleton births in Finland in 1997-2010. BJOG 2014; 121 (08) 965-970 DOI: 10.1111/1471-0528.12599. https://doi.org/10.1111/1471-0528.12599...	Finland, 2014	Cohort study, FOC associations with risk factors and perinatal outcomes	N/A	High and unspecified socioeconomic status, advanced maternal age, and depression are predisposing factors for FOC regardless of parity. Among multiparous women, a previous CS increases vulnerability to FOC. Fear of childbirth is associated with increased rates of cesarean section but does not affect adversely other pregnancy outcomes.
Fear of childbirth in women with normal pregnancy evolution.⁷7 Aksoy AN, Ozkan H, Gundogdu G. Fear of childbirth in women with normal pregnancy evolution. Clin Exp Obstet Gynecol 2015; 42 (02) 179-183	Finland, 2015	Survey study, 817 women, FOC and previous birth experience	N/A	Fear of childbirth may be seen to some extent in women with a positive birth experience.
Fear of birth in clinical practice: a structured review of current measurement tools.⁸8 Richens Y, Smith DM, Lavender DT. Fear of birth in clinical practice: A structured review of current measurement tools. Sex Reprod Healthc 2018; 16: 98-112 DOI: 10.1016/j.srhc.2018.02.010. https://doi.org/10.1016/j.srhc.2018.02.0...	UK, 2018	Review, 46 studies	N/A	The Fear of Birth Scale (FOBS) has been shown to be as effective as the W-DEQ but has the advantage of being short and easy to administer.
Tokophobia: an unreasoning dread of childbirth. A series of 26 cases.⁹9 Hofberg K, Brockington I. Tokophobia: an unreasoning dread of childbirth. A series of 26 cases. Br J Psychiatry 2000; 176: 83-85 DOI: 10.1192/bjp.176.1.83. https://doi.org/10.1192/bjp.176.1.83...	UK, 2000	Quantitative analysis interview, 46 women	N/A	Tokophobia is a specific and harrowing condition that needs acknowledging. Close liaison between the obstetrician and the psychiatrist in order to assess the balance between surgical and psychiatric morbidity is imperative with tokophobia.
Tokophobia: A profound dread and avoidance of childbirth (when pathological fear effects the consultation).¹⁰10 Hofberg K, Ward M. Tokophobia tokophobia: a profound dread and avoidance of childbirth (when pathological fear effects the consultation). In: Cockburn J, Pawson ME. editors. Psychological challenges in obstetrics and gynecology. London: Springer; 2007: 165-72	2007	Book chapter	N/A	N/A
Contents of childbirth-related fear among couples wishing the partner's presence at delivery.¹¹11 Szeverényi P, Póka R, Hetey M, Török Z. Contents of childbirth-related fear among couples wishing the partner's presence at delivery. J Psychosom Obstet Gynaecol 1998; 19 (01) 38-43 DOI: 10.3109/01674829809044219. https://doi.org/10.3109/0167482980904421...	Hungary, 1998	Survey, 216 pairs of prospective parents	N/A	Eighty per cent of women and 76% of men felt that the presence of the partner at delivery would have no adverse effect on their future personal relationship.
Fear of childbirth according to parity, gestational age, and obstetric history.¹²12 Rouhe H, Salmela-Aro K, Halmesmäki E, Saisto T. Fear of childbirth according to parity, gestational age, and obstetric history. BJOG 2009; 116 (01) 67-73 DOI: 10.1111/j.1471-0528.2008.02002.x. https://doi.org/10.1111/j.1471-0528.2008...	Finland, 2008	Survey study	N/A	To examine FOC according to parity, gestational age, and obstetric history. Severe fear of childbirth was more common in nulliparous women, in later pregnancy, and in women with previous cesarean section or VE. Cesarean section as a preferred mode of childbirth was strongly associated with high scores in both the W-DEQ and the VAS.
Identifying women are afraid of giving birth: A comparison of the fear of birth scale with the W-DEQ A in a large Australian cohort.¹³13 Haines HM, Pallant JF, Fenwick J, Gamble J, Creedy DK, Toohill J. et al. Identifying women who are afraid of giving birth: A comparison of the fear of birth scale with the WDEQ-A in a large Australian cohort. Sex Reprod Healthc 2015; 6 (04) 204-210 DOI: 10.1016/j.srhc.2015.05.002. https://doi.org/10.1016/j.srhc.2015.05.0...	Australia, 2015	To compare the two-item FOBS with the 33-item WDEQ-A in a large cohort of Australian pregnant women, 1,410 women	N/A	Self-report questionnaires during the 2^nd trimester, including the WDEQ-A and the FOBS. This study supports the use of the FOBS in clinical practice to identify childbirth fear in pregnant women.
Exploring the Fear of Birth Scale in a mixed population of women of childbearing age-A Swedish pilot study.¹⁴14 Hildingsson I, Rubertsson C, Karlström A, Haines H. Exploring the Fear of Birth Scale in a mixed population of women of childbearing age-A Swedish pilot study. Women Birth 2018; 31 (05) 407-413 DOI: 10.1016/j.wombi.2017.12.005. https://doi.org/10.1016/j.wombi.2017.12....	Sweden, 2018	A cross-sectional mixed method study of 179 women	N/A	To explore the FOBS in a mixed sample of women of childbearing age
Fear of childbirth: predictors and temporal changes among nulliparous women in the Danish National Birth Cohort.¹⁵15 Laursen M, Hedegaard M, Johansen C. Danish National Birth Cohort. Fear of childbirth: predictors and temporal changes among nulliparous women in the Danish National Birth Cohort. BJOG 2008; 115 (03) 354-360 DOI: 10.1111/j.1471-0528.2007.01583.x. https://doi.org/10.1111/j.1471-0528.2007...	Denmark, 2008	Cohort of 30 480 healthy nulliparous women with uncomplicated singleton pregnancies.	N/A	To describe the association between FOC and social, demographic, and psychological factors
Fear of childbirth in obstetrically low-risk nulliparous women in Sweden and Denmark.¹⁶16 Kjærgaard H, Wijma K, Dykes A, Alehagen S. Fear of childbirth in obstetrically low-risk nulliparous women in Sweden and Denmark. J Reprod Infant Psychol 2008; 26 (04) 340-350 DOI: 10.1080/02646830802408498. https://doi.org/10.1080/0264683080240849...	Sweden, 2008	165 women	N/A	The objectives of this study were to compare FOC among Danish and Swedish nulliparous women and to investigate a possible difference in FOC between women who, during pregnancy, had met the midwife who they were subsequently coincidentally allocated to receive labor care from and women who had not previously met the midwife.
Fear of childbirth and duration of labour: a study of 2206 women with intended vaginal delivery.¹⁷17 Adams SS, Eberhard-Gran M, Eskild A. Fear of childbirth and duration of labour: a study of 2206 women with intended vaginal delivery. BJOG 2012; 119 (10) 1238-1246 DOI: 10.1111/j.1471-0528.2012.03433.x. https://doi.org/10.1111/j.1471-0528.2012...	Norway, 2012	Prospective study with 2,206 pregnant women	N/A	Duration of labor was longer in women with FOC than in women without FOC
Cross cultural comparison of levels of childbirth related fear in an Australian and Swedish sample.¹⁸18 Haines H, Pallant JF, Karlström A, Hildingsson I. Cross-cultural comparison of levels of childbirth-related fear in an Australian and Swedish sample. Midwifery 2011; 27 (04) 560-567 DOI: 10.1016/j.midw.2010.05.004. https://doi.org/10.1016/j.midw.2010.05.0...	Australia, 2011	Survey study, 509 women	N/A	To evaluate the range of childbirth-related issues
Higher prevalence of childbirth related fear in foreign born pregnant women–findings from a community sample in Sweden.¹⁹19 Ternström E, Hildingsson I, Haines H, Rubertsson C. Higher prevalence of childbirth related fear in foreign born pregnant women–findings from a community sample in Sweden. Midwifery 2015; 31 (04) 445-450 DOI: 10.1016/j.midw.2014.11.011. https://doi.org/10.1016/j.midw.2014.11.0...	Sweden, 2015	Cross-sectional prevalence study,	N/A	To investigate the prevalence of CBRF in early pregnancy
Childbirth fear, anxiety, fatigue and sleep deprivation in pregnant women.²⁰20 Hall WA, Hauck YL, Carty EM, Hutton EK, Fenwick J, Stoll K. Childbirth fear, anxiety, fatigue, and sleep deprivation in pregnant women. J Obstet Gynecol Neonatal Nurs 2009; 38 (05) 567-576 DOI: 10.1111/j.1552-6909.2009.01054.x. https://doi.org/10.1111/j.1552-6909.2009...	Canada, 2009	Cross-sectional descriptive survey, 650 women	N/A	To explore women's levels of childbirth fear, sleep deprivation, anxiety, and fatigue and their relationships during the 3^rd trimester of pregnancy.
Women's lived experience of fear of childbirth.²¹21 Nilsson C, Lundgren I. Women's lived experience of fear of childbirth. Midwifery 2009; 25 (02) e1-e9 DOI: 10.1016/j.midw.2007.01.017. https://doi.org/10.1016/j.midw.2007.01.0...	Sweden, 2009	Qualitative study, 8 women	N/A	Four constituents were identified: feeling of danger that threatens and appeals; feeling trapped; feeling like an inferior mother-to-be, and on your own. The essential structure was described as 'to lose oneself as a woman into loneliness'.
A cognitive model of social phobia.²²22 Clark DM, Wells A. A cognitive model of social phobia. In: Heimberg RG, Liebowitz MR, Hope DA, Schneier FR. Social phobia: diagnosis, assessment, and treatment. New York: Guilford; 1995: 69-93	USA, 2007	Systematic review, 4 studies	N/A	N/A
Cognitive biases and the emotional disorders.²³23 Mineka S, Sutton SK. Cognitive biases and the emotional disorders. Psychol Sci 1992; 3 (01) 65-69 DOI: 10.1111/j.1467-9280.1992.tb00260.x. https://doi.org/10.1111/j.1467-9280.1992...	USA, 1992	Book	N/A	Finally, selective associations in fear conditioning are a form of associative bias implicated in the origins of fears and phobias.
Development of the Delivery Fear Scale.²⁴24 Wijma K, Alehagen S, Wijma B. Development of the Delivery Fear Scale. J Psychosom Obstet Gynaecol 2002; 23 (02) 97-107 DOI: 10.3109/01674820209042791. https://doi.org/10.3109/0167482020904279...	Sweden, 2009	Questionnaire development, 135 patients	N/A	This article reviews the development of the DFS to measure fear during labor and delivery.
Pregnant women's thoughts when assessing fear of birth on the Fear of Birth Scale.²⁵25 Ternström E, Hildingsson I, Haines H, Rubertsson C. Pregnant women's thoughts when assessing fear of birth on the Fear of Birth Scale. Women Birth 2016; 29 (03) e44-e49 DOI: 10.1016/j.wombi.2015.11.009. https://doi.org/10.1016/j.wombi.2015.11....	Sweden, 2016	Qualitative design using semi-structured interviews, 31 pregnant women	N/A	Women thought about aspects that influence their worries and fears and explained the strategies that helped them to cope with their FOC, supporting the use of the FOBS in clinical settings
Causes and outcomes in studies of fear of childbirth: A systematic review.²⁶26 Dencker A, Nilsson C, Begley C. et al. Causes and outcomes in studies of fear of childbirth: A systematic review. Women Birth 2019; 32 (02) 99-111 DOI: 10.1016/j.wombi.2018.07.004. https://doi.org/10.1016/j.wombi.2018.07....	Sweden, 2019	Systematic review, 21 studies	N/A	To summarize the findings of published studies regarding possible causes/predisposing factors and outcomes of FOC for childbearing women.
Secondary fear of childbirth prolongs the time to subsequent delivery.²⁷27 Sydsjö G, Angerbjörn L, Palmquist S, Bladh M, Sydsjö A, Josefsson A. Secondary fear of childbirth prolongs the time to subsequent delivery. Acta Obstet Gynecol Scand 2013; 92 (02) 210-214 DOI: 10.1111/aogs.12034. https://doi.org/10.1111/aogs.12034...	Sweden, 2013	Descriptive, retrospective case-control study, 990 patients	N/A.	The aim of this study was to investigate the time to subsequent delivery and delivery outcome in women with secondary FOC compared with a reference group.
Fear of childbirth and risk for birth complications in nulliparous women in the Danish National Birth Cohort.²⁸28 Laursen M, Johansen C, Hedegaard M. Fear of childbirth and risk for birth complications in nulliparous women in the Danish National Birth Cohort. BJOG 2009; 116 (10) 1350-1355 DOI: 10.1111/j.1471-0528.2009.02250.x. https://doi.org/10.1111/j.1471-0528.2009...	Denmark, 2009	Prospective cohort study, 25 297 women, computer-assisted telephone interviews	N/A	Risk for emergency cesarean section of women who feared childbirth; risk for dystocia/protracted labor or fetal distress of women who feared childbirth
Fear of childbirth and preference for cesarean delivery among young american women before childbirth.²⁹29 Stoll K, Edmonds JK, Hall WA. Fear of childbirth and preference for cesarean delivery among young american women before childbirth: a survey study. Birth 2015; 42 (03) 270-276 DOI: 10.1111/birt.12178. https://doi.org/10.1111/birt.12178...	USA, 2015	Online survey with 752 women	N/A	Young women reporting high levels of childbirth fear are nearly four times more likely to prefer a cesarean section. Specific fears, such as worries over the influence of pregnancy and birth on the female body, need to be addressed before pregnancy.
Fear of childbirth and elective caesarean section: a population-based study.³⁰30 Størksen HT, Garthus-Niegel S, Adams SS, Vangen S, Eberhard-Gran M. Fear of childbirth and elective caesarean section: a population-based study. BMC Pregnancy Childbirth 2015; 15: 221 DOI: 10.1186/s12884-015-0655-4. https://doi.org/10.1186/s12884-015-0655-...	Norway, 2015	Cohort study, 1789 women	N/A	Women with FOC may have identifiable vulnerability characteristics, such as poor mental health and poor social support.
Fear of childbirth and risk of caesarean delivery: a cohort study in six European countries.³¹31 Ryding EL, Lukasse M, Parys AS, Wangel A-M, Karro H, Kristjansdottir H. et al; Bidens Group. Fear of childbirth and risk of cesarean delivery: a cohort study in six European countries. Birth 2015; 42 (01) 48-55 DOI: 10.1111/birt.12147. https://doi.org/10.1111/birt.12147...	Sweden, 2015	Longitudinal cohort study, 6,422 women	N/A	Having severe FOC increases the risk of elective cesarean delivery, especially among multiparous women. Lack of positive anticipation of the upcoming childbirth seems to be an important dimension of fear associated with cesarean delivery.
The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework.³²32 Ayers S, Bond R, Bertullies S, Wijma K. The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework. Psychol Med 2016; 46 (06) 1121-1134 DOI: 10.1017/S0033291715002706. https://doi.org/10.1017/S003329171500270...	UK, 2016	Meta-analysis, 50 studies	N/A	Risk factors in birth most strongly associated with PTSD were negative subjective birth experiences (r = 0.59), having an operative birth (assisted vaginal or cesarean, r = 0.48), lack of support (r = -0.38), and dissociation (r = 0.32).

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[1] Address for correspondence Elaine Christine Dantas Moises, Av Bandeirantes, 3900, Campus da Universidade de São Paulo, 14049-900, Ribeirão Preto, SP, Brazil (e-mail: elainemoises@fmrp.usp.br).