Collaboration on fear of childbirth

02 December 2017
Volume 25 · Issue 12


In Ireland, as in many other countries, perinatal tocophobia is an under-explored condition. With EU funding, Maeve O'Connell travelled to Sweden to meet the midwives helping expectant mothers

Last year, at a conference held in Trinity College Dublin, I attended a presentation by a Swedish midwifery researcher, Professor Ingegerd Hildingsson. She presented her research findings on fear of childbirth, an area she has been researching for over 15 years, and spoke about well-established clinics for women with fear of childbirth in Sweden. Although the clinics were not preceded by an randomised controlled trial, they were set up in the 1990s by the Aurora Midwives—a team of midwifery professionals who saw a need for them. They meet women and talk through their fears, creating birth plans with them and providing reassurance. Women have evaluated their care positively, and have had good birth experiences and fewer caesarean births.

I was intrigued; I had read about these midwives in the literature and was keen to learn more, as my PhD is on tocophobia (severe fear of childbirth) in Ireland.

After the presentation, I introduced myself and we talked about the research that I have carried out to date. I am the first person to research tocophobia in Ireland, where we have no dedicated service. Much of the research focus has been related to the fact that women with tocophobia may often request a caesarean section. But in addition, I see tocophobia as a perinatal mental health issue, because evidence suggests women with tocophobia are more likely to have pre-existing mental health issues, such as anxiety and depression, and are more likely to have postnatal depression and post-traumatic stress disorder (PTSD) after the birth. We know that women with low social supports are more likely to experience tocophobia, making already vulnerable women even more so.

Professor Christine Rubertsson, Professor Ingegerd Hildingsson, Maeve O'Connell, Ingela Tegman, Marianne Kordel and Dr. Elin Ternstrom at Uppsala University

Public perinatal mental health services are greatly lacking and under-resourced globally. In fact, in Cork, where I am based, there no specific perinatal psychiatrist in a hospital with approximately 8000 births per year. In Ireland, the three (part-time) perinatal psychiatrists are based in Dublin, so services are considerably over-stretched. The 2016 National Maternity Strategy has called for additional awareness, screening and support for perinatal mental health in Ireland.

Tocophobia may have an impact on women's psychological and physical health. Women may have panic attacks, insomnia and nightmares; catastrophise pain and birth outcomes; or may fear for their infant's life, among other things. Fear of childbirth has been recognised as a psychological domain in its own right and it may have a similar action as stress in pregnancy. There is good evidence from a large epidemiological population-based study in Finland that, in women without a history of depression, women with fear of childbirth are almost three times as likely to develop postpartum depression. Moreover, fear of childbirth has been associated with longer labours, caesarean births, and greater use of epidural; and may influence infant bonding, attachment and partner relationships. I led a team of researchers who carried out a systematic review and meta-analysis which looked at the global prevalence of tocophobia and we found that it may affect up to 14% of women. It also appears to have become more prevalent since 2000. However, we found that prealence rates reported varied widely, from 3.7-43%, which may be attributed to a lack of an agreed definition.

I heard about the European Cooperation in Science and Technology (COST) programme, an EU-funded scheme that facilitates researchers to set up interdisciplinary research networks abroad, and I felt that collaboration with Professor Hildingsson would be a fantastic opportunity, both for my research and to progress the body of knowledge on fear of childbirth. I put together an application with the support of Professor Hildingsson in March, and was delighted when I was awarded the travel bursary in April this year.

Uppsala is a beautiful university city in Sweden. It has a population of about 200 000 people, with approximately 2500 births per year. Professor Hildingsson gave me a warm welcome, which included the Swedish tradition of fika (coffee and cake). During my trip, I had the opporunity to meet with the women's health team at Uppsala University, and took a trip to Sundsvall, a city north of Uppsala, to visit the Aurora midwives.

On Monday afternoon, I presented my PhD work to a group of researchers and two Aurora midwives, Ingela Tegman and Marianne Kordel. Meeting them face-to-face was a wonderful experience, and we had great discussions about our research and our experiences of working with women with fear of childbirth. It was amazing to feel such passion and dedication to women's health in one room. This was a crucial part of the research process: hearing about their research first-hand and discussing the challenges met throughout. It became obvious to me that although we are working in completely different parts of the world, the women are the same—and many of the issues are, too.

‘We are a group of researchers with a common goal, to improve women's health and well-being and to deliver a positive birth experience for women so that families have the best start in life’

I then met with Dr Annika Karlstrom and Dr Birgitta Larsson in Sundsvall, a picturesque coastal town 395 km north of Stockholm, which is home to the Aurora midwives. The unit has approximately 1700 births per year, and the midwives here offer midwife-led counselling for women with fear of childbirth. Birgitta was one of the founding Aurora midwives and recently defended her thesis, entitled: ‘Treatment for childbirth fear with a focus on midwife-led counselling’. She explained that the midwives have no formal counselling education, and they are usually midwives from the labour ward who express an interest in working with women with fear of childbirth.

These counselling sessions normally happen from about 25 weeks, and last 1 hour. The partner may or may not be present, and there can be two or three sessions, depending on the woman's needs. At times, if the fear is very severe, or the woman has other mental health issues, a referral may be made to a perinatal psychiatrist for additional support. The counselling focuses on describing the birth process, delivering antenatal education, and ensuring that women's fears and stories are listened to. The women are given resources, such as breathing techniques and other relevant antenatal information. Ensuring that women have a good understanding of the normal birth process is very important.

The trip reminded me of the saying, ‘If you want to go fast, go alone; if you want to go far, go together.’ We are a group of researchers with a common goal: to improve women's health and wellbeing and to deliver a positive birth experience for women, so that families can have the best possible start in life.