Pregnancy and birth are described as a transition phase or existential threshold that childbearing women must cross. Childbirth is an experience with multifaceted dimensions and is unique for each woman, as well as being strongly influenced by her psychosocial context. Women's expectations and experiences of pregnancy and birth are both positive and negative in nature, involving feelings of joy and faith but also worries, anxiety and fears (Dencker et al, 2019).
Although maternity care in high-income countries is safe, fear of childbirth is a common problem affecting the health and wellbeing of women before, during and after pregnancy. Fear of childbirth can result in consequences for women's relationships with their baby, partner and family, and often leads to a higher rate of childbirth interventions and requests for caesarean section by women striving for control in an exposed situation (Nilsson et al, 2018). Fear of childbirth has also been shown to be associated with emergency caesarean section, increased risk of dystocia, protracted labour, preterm birth, low birth weight, unsuccessful breastfeeding, extended postnatal hospital stay and a negative childbirth experience (Waldenström et al, 2006; Laursen et al, 2009).
Parity is a crucial factor associated with fear of childbirth. There are controversial reports in the literature regarding the association between parity and fear of childbirth, and little is known about comparing pregnancy, labour and birth outcomes in nulliparous and multiparous mothers who are afraid of childbirth. Various factors have been reported for fear of childbirth in multiparous women, such as prior negative (Dahlberg and Aune, 2013) or traumatic birth experiences (Eide et al, 2019), maltreatment during labour and birth (Mannava et al, 2015), prolonged labour, lack of support during labour and birth, and medical interventions (Drew et al, 2016). In nulliparous women, fear of childbirth may be associated with fear of having a vaginal birth (Eide et al, 2019), negative childbirth self-efficacy (Skitmore, 2015), social isolation and negative emotions (Moghaddam Hosseini et al, 2019).
Based on the literature, several important questions that remain unanswered. There is considerable variability in prevalence estimates for fear of childbirth among nulliparous and multiparous women. In addition, evidence to date is inconclusive regarding whether fear of childbirth is associated with adverse birth outcomes. No recent research has been done at the authors’ hospital assessing the mental health of perinatal patients, in particular their fear of childbirth, and following them up after birth. This indicated an urgent need to investigate this important issue.
Methods
Study design and setting
This mixed-methods prospective cohort study was conducted at Westmead Hospital's antenatal clinic.
Sample size
The primary outcome of the study was severe fear of childbirth. To calculate sample size, it was assumed that 60% of the cohort would be multiparous (based on hospital records) and that the prevalence of fear of childbirth was 18% in multiparous and 31% in nulliparous women, based on an earlier study (Toohill et al, 2014). This gave a final sample size of ≥141 nulliparous women and 212 multiparous women (a total of 353 participants) to allow subgroup analysis of the multiparous and nulliparous women while maintaining 80% power. The calculated sample size would have more than 80% power to detect a difference in the rate of birth outcomes between women with and without fear of childbirth, assuming that 70% of nulliparous women and 80% of multiparous women do not have fear of childbirth. All comparisons have a two-sided alpha of 5%.
Participants
Pregnant women were invited to participate in the study, based on the following inclusion criteria: age ≥18 years, in the second or third trimester of pregnancy with a singleton baby, low-risk pregnancy and permanent residency in Australia. Women were excluded from the study if they did not speak English and if they had a high-risk pregnancy or had been clinically diagnosed with perinatal mental health issues.
Outcomes
The primary outcome was the prevalence of fear of childbirth in nulliparous and multiparous women. The secondary maternal outcomes were induction of labour, uterine activity on admission, pain relief (non-pharmacological and epidural analgesia), mode of birth (including normal vaginal birth, instrumental birth and caesarean section), perineal damage and postpartum haemorrhage. The secondary neonatal outcomes were gestational age at birth, Apgar score at 5 minutes, birth weight, resuscitation after birth, special care nursery admission after birth and type of feeding at discharge.
Outcome measures
After a comprehensive literature review, a multi-section self-report questionnaire was designed, requesting information on social and demographic circumstances, obstetrics and medical history, maternity care during current pregnancy, labour and birth details and the newborn's characteristics. Three standardised questionnaires were also used.
The Wijma delivery expectancy/experience questionnaire
The Wijma delivery expectancy/exper ience questionnaire (W-DEQ) was used to measure fear of childbirth during pregnancy based on a woman's cognitive appraisal of the birth. The W-DEQ is a validated 33-item questionnaire, with scores ranging from 0 (‘not at all’) to 5 (‘extremely’), with a minimum score of 0 and a maximum score of 165. A higher score indicates a more intense fear of childbirth. The answers to questions that are positively formulated (items 2, 3, 6, 7, 8, 11, 12, 15, 19, 20, 24, 25, 27, 31) are reversed for calculation of the women's individual sum score. A W-DEQ score of ≤37 is an indication of low fear, 38–65 shows moderate fear, 66–84 indicates high fear, and ≥85 is classified as having severe fear of childbirth (Wijma et al, 1998; O'Connell et al, 2019).
Fear of birth scale
The fear of birth scale (FoBS) contains a two-item visual analogue scale that explores worry and fear about an upcoming birth by asking the question,‘how do you feel right now about approaching birth?’ (Haines et al, 2011). The score ranges from 0–100; a higher score indicates higher fear of childbirth, and a cut-off score of 50 was applied in the present study to indicate fear of childbirth.
Depression, anxiety and stress scale-21
The short version of the depression, anxiety and stress scale (DASS) questionnaire, containing a set of three self-report scales, was used to measure anxiety, depression and stress during pregnancy and after childbirth. DASS has been shown to have high internal consistency and yield meaningful discriminations in various settings (Bibi et al, 2020). It should meet the needs of both researchers and clinicians wishing to measure the current state, or change in state over time, on the three dimensions of depression, anxiety and stress.
Each scale contains seven items. Respondents were asked to use 4-point severity/frequency scales to rate the extent to which they experienced each state over the past week. Scores for depression, anxiety and stress were calculated by summing the scores for the relevant items (Osman et al, 2012).
Data collection
The researcher approached pregnant women who met the inclusion criteria in the antenatal clinic and invited them to participate in the study. The women were given enough time to read the information sheet and ask questions. Those who were interested signed written consent and added their medical record number for the collection of birth details. They were given a study ID and asked to provide their mobile number and email address to receive online questionnaires. After they received the link to the online questionnaire, they read a short information sheet on the first page of the survey and moved to the following pages to answer the questions while they were still at the hospital.
After women gave birth, their labour and birth details were collected from the eMaternity database using the medical record number provided at baseline. The time required to complete the online questionnaires at each point was approximately 20–30 minutes.
Data analysis
The Statistical Package for Social Siences Advanced Statistics (version 24.0, Chicago, IL, USA) was used to analyse the data. After completing the online questionnaire on Survey Monkey, participants' replies were downloaded into an Excel file. Each response choice was coded and assigned a numerical value. The complete dataset was imported into the software for analysis.
The sociodemographic, obstetric and medical history, mental health, sexual function, relationship data (independent variables), prevalence of fear of childbirth (dependent variable) and birth outcomes were summarised using descriptive statistics. The primary outcome, fear of childbirth, was analysed as both a continuous (W-DEQ and FoBS) and dichotomous variable at the same time.
Continuous variables were shown as mean ± standard deviation, while categorical variables were shown as frequency (%) in relevant categories. The Chi-squared test was used to examine the relationship between fear of childbirth and independent factors. The role of multiple factors influencing the likelihood of fear of childbirth was investigated using multivariate logistic regression analysis (backward Wald). P<0.05 was considered statistically significant.
Ethical considerations
This protocol received institutional Human Research Ethics Committee approval prior to its commencement. The participants signed written informed consent sheets before participating in the study, and data were anonymised through the use of ID numbers for participants.
Results
A total of 141 nulliparous women and 212 multiparous women completed the W-DEQ and FoBS questionnaires (the primary outcome). The DASS questionnaire was completed by 138 nulliparous women and 204 multiparous women.
Prevalence of fear of childbirth
According to the W-DEQ scores (Table 1), the prevalence of fear of childbirth was 33% in nulliparous women and 31% in multiparous women (P=0.697). Analysis of responses to the FoBS showed that among nulliparous women, 37% were moderately–very worried about the approaching birth, and 36% had moderate–high fear of the approaching birth. These rates were 42% and 40%, respectively, in multiparous women. For both worry and fear, the differences between nulliparous and multiparous women were not statistically significant.
Table 1. Comparison of fear of childbirth
| Variable | Frequency, n (%) | Relative risk (95% confidence interval) | P value | ||
|---|---|---|---|---|---|
| Nulliparous, n=141 | Multiparous, n=212 | ||||
| W-DEQ | Low–moderate fear (≤65) | 95 (67.4) | 147 (69.3) | 1.04 (0.86–1.25) | 0.697 |
| High–severe (>65) | 46 (32.6) | 65 (30.7) | 0.95 (0.72–1.24) | ||
| Mean ± standard deviation | 81 ± 17 | 78 ± 12 | – | ||
| Feeling calm about the approaching birth | Moderately to very calm (<50) | 89 (63.1) | 123 (58.0) | 0.92 (0.78–1.09) | 0.338 |
| Moderately to very worried (≥50) | 52 (36.9) | 89 (42.0) | 1.14 (0.87–1.49) | ||
| Mean ± standard deviation | 49 ± 27 | 54 ± 29 | – | ||
| Feeling fear about the approaching birth | No or mild fear (<50) | 91 (64.5) | 127 (59.9) | 0.93 (0.78–1.10) | 0.380 |
| Moderate to high fear (≥50) | 50 (35.5) | 85 (40.1) | 1.13 (0.86–1.48) | ||
| Mean ± standard deviation | 51 ± 28 | 50 ± 27 | – | ||
Risk factors of fear of childbirth
Table 2 shows a comparison of the sociodemographic characteristics of women with high–severe fear of childbirth. Nulliparous women were more likely than their multiparous counterparts to have a lower family income (≤$50000) (65.2% vs 27.7%, P<0.001), attend antenatal educational classes (34.8% vs 10.8%, P=0.002) and have assisted conception (10.9% vs 1.5%, P=0.032). Although not statistically significantly different, women with high–severe fear of childbirth in both groups were more likely to be younger, have a diploma or tertiary education, have been born in other countries, not have formal employment, have a history of miscarriage/abortion, have support persons, not drink alcohol or smoke cigarettes and had planned pregnancy with no history of medical problems. Nulliparous women with high–severe fear of childbirth were more likely to report severe–extremely severe symptoms of depression (34.1% vs 6.6%, P<0.001), anxiety (50.0% vs 27.9%, P=0.021) and stress (34.1% vs 6.6%, P<0.001) than multiparous women with high–severe fear of childbirth (Table 3).
Table 2. Comparison of sociodemographic characteristics in women with high–severe fear of childbirth
| Variable | Frequency of high–severe fear of childbirth, n (%) | Relative risk (95% confidence interval) | P value | ||
|---|---|---|---|---|---|
| Nulliparous, n=46 | Multiparous, n=65 | ||||
| Age (years) | ≤35 | 36 (78.3) | 43 (66.2) | 0.79 (0.58–1.08) | 0.165 |
| >35 | 10 (21.7) | 22 (33.8) | 1.46 (0.83–4.39) | ||
| Education | High school certificate or lower | 8 (17.4) | 19 (29.2) | 1.29 (0.94–1.76) | 0.152 |
| Diploma or tertiary education | 38 (82.6) | 46 (70.8) | 0.66 (0.35–1.23) | ||
| Country of birth | Australia | 10 (21.7) | 16 (24.6) | 1.07 (0.75–1.52) | 0.724 |
| Other | 36 (78.3) | 49 (75.4) | 0.91 (0.53–1.57) | ||
| Country of origin | Australia | 16 (34.8) | 15 (23.1) | 0.77 (0.52–1.16) | 0.176 |
| Other | 30 (65.2) | 50 (76.9) | 1.38 (0.88–2.14) | ||
| Employment status | Not working | 25 (54.3) | 33 (50.8) | 0.94 (0.69–1.29) | 0.710 |
| Formal occupation | 21 (45.6) | 32 (49.2) | 1.09 (0.70–1.70) | ||
| History of miscarriage/abortion | No | 28 (60.9) | 35 (53.8) | 0.89 (0.65–1.21) | 0.462 |
| Yes | 18 (39.1) | 30 (46.2) | 1.19 (0.75–1.87) | ||
| Marital status | Married/de facto | 44 (95.7) | 57 (87.7) | 0.71 (0.50–1.01) | 0.149 |
| Single mother | 2 (4.3) | 8 (12.3) | 2.18 (0.62–7.67) | ||
| Annual family income ($) | ≤50000 | 30 (65.2) | 18 (27.7) | 0.50 (0.34–0.74) | <0.001 |
| >50000 | 16 (34.8) | 47 (72.3) | 2.46 (1.53–3.96) | ||
| Support person | Self only | 3 (6.5) | 5 (7.7) | 1.07 (0.61–1.88) | 0.814 |
| Others | 43 (93.5) | 60 (92.3) | 0.90 (0.36–2.26) | ||
| Major life stressors | No | 27 (58.7) | 38 (58.5) | 1.00 (0.73–1.34) | 0.980 |
| Yes | 19 (41.3) | 27 (41.5) | 1.01 (0.64–1.58) | ||
| Alcohol intake during pregnancy | No | 44 (95.7) | 64 (98.5) | 1.78 (0.36–8.88) | 0.369 |
| Yes | 2 (4.3) | 1 (1.5) | 0.61 (0.27–1.40) | ||
| Cigarette smoking during pregnancy | No | 45 (97.8) | 63 (96.9) | 0.88 (0.39–1.98) | 0.773 |
| Yes | 1 (2.2) | 2 (3.1) | 1.25 (0.25–6.29) | ||
| History of childhood sexual assault | No | 43 (93.5) | 59 (90.8) | 0.87 (0.53–1.42) | 0.606 |
| Yes | 3 (6.5) | 6 (9.2) | 1.27 (0.49–3.28) | ||
| History of adult sexual assault | No | 44 (95.7) | 63 (96.9) | 1.18 (0.44–3.18) | 0.723 |
| Yes | 2 (4.3) | 2 (3.1) | 0.82 (0.30–2.25) | ||
| Attended antenatal education | No | 30 (65.2) | 58 (89.2) | 2.17 (1.15–4.09) | 0.002 |
| Yes | 16 (34.8) | 7 (10.8) | 0.49 (0.33–0.73) | ||
| Conception planning | Planned/intended | 33 (71.7) | 38 (58.5) | 0.79 (0.58–1.08) | 0.151 |
| Unplanned/unintended | 13 (28.3) | 27 (41.5) | 1.43 (0.86–2.39) | ||
| Conception assistance | Spontaneous | 41 (89.1) | 64 (98.5) | 3.66 (0.61–22.03) | 0.032 |
| Assisted | 5 (10.9) | 1 (1.5) | 0.47 (0.31–0.72) | ||
| History of medical problems | No | 33 (71.7) | 34 (52.3) | 0.72 (0.53–0.98) | 0.039 |
| Yes | 13 (28.3) | 31 (47.7) | 1.67 (1.01–2.80) | ||
| Body mass index | Mean ± standard deviation | 27.0 ± 5.2 | 27.9 ± 5.9 | 0.88 (–1.30–3.05) | 0.426 |
| Duration of Australian residency (years) | Mean ± standard deviation | 12.4 ± 11.3 | 16.6 ± 11.6 | 4.23 (–0.17–8.62) | 0.058 |
Table 3. Comparison of depression, anxiety and stress
| Variable | Frequency of high–severe fear of childbirth, n (%) | Relative risk (95% confidence interval) | P value | ||
|---|---|---|---|---|---|
| Nulliparous, n=44 | Multiparous, n=61 | ||||
| Depression | Mild–moderate symptoms (0–10) | 29 (65.9) | 57 (93.4) | 3.15 (1.30–7.62) | <0.001 |
| Severe–extremely severe symptoms (>10) | 15 (34.1) | 4 (6.6) | 0.42 (0.29–0.62) | ||
| Mean ± standard deviation | 8 ± 8 | 4 ± 4 | – | ||
| Anxiety | Mild–moderate symptoms (0–7) | 22 (50.0) | 44 (72.1) | 1.53 (1.03–2.27) | 0.021 |
| Severe–extremely severe symptoms (>7) | 22 (50.0) | 17 (27.9) | 0.59 (0.38–0.92) | ||
| Mean ± standard deviation | 9 ± 8 | 5 ± 5 | – | ||
| Stress | Mild–moderate symptoms (0–12) | 29 (65.9) | 57 (93.4) | 3.15 (1.30–7.62) | <0.001 |
| Severe–extremely severe symptoms (>12) | 15 (34.1) | 4 (6.6) | 0.43 (0.29–0.62) | ||
| Mean ± standard deviation | 11 ± 8 | 6 ± 5 | – | ||
Birth outcomes
Birth data were not available for every woman, as only 130 of the 141 nulliparous women and 195 of the 212 multiparous women gave birth in the study hospital. Of those who did, 42 nulliparous and 62 multiparous women had high–severe fear of childbirth. Nulliparous women with high–severe fear of childbirth were more likely than their multiparous counterparts to have prelabour cervical ripening (23.8% vs 6.5%, P=0.011), receive oxytocin for induction or augmentation of labour (88.1% vs 61.3%, P=0.003), have an instrumental birth (14.3% vs 3.2%, P=0.045), have an episiotomy (45.0% vs 11.1%, P=0.040) and greater volume of blood loss during birth (564.6ml vs 346.5ml, P=0.010). No other statistically significant differences were found between the two groups in terms of maternal and neonatal outcomes (Table 4).
Table 4. Comparison of birth outcomes between nulliparous and multiparous women with high–severe fear of childbirth
| Variable | Frequency of high–severe fear of childbirth, n (%) | Relative risk (95% confidence interval) | P value | ||
|---|---|---|---|---|---|
| Nulliparous, n=42 | Multiparous, n=62 | ||||
| Prelabour cervical ripening | No | 32 (76.2) | 58 (93.5) | 2.26 (0.97–5.24) | 0.011 |
| Yes | 10 (23.8) | 4 (6.5) | 0.50 (0.32–0.78) | ||
| Uterine activity on admission | Yes | 31 (73.8) | 34 (54.8) | 0.73 (0.54–0.99) | 0.050 |
| No | 11 (26.2) | 28 (45.2) | 1.69 (0.96–2.97) | ||
| Oxytocin use in labour | No | 5 (11.9) | 24 (38.7) | 1.63 (1.24–2.16) | 0.003 |
| Yes | 37 (88.1) | 38 (61.3) | 0.35 (0.15–0.80) | ||
| Non-pharmacological pain management | No | 24 (57.1) | 35 (56.5) | 0.99 (0.72–1.36) | 0.944 |
| Yes | 18 (42.9) | 27 (43.5) | 1.02 (0.63–1.63) | ||
| Mode of birth | Normal vaginal birth | 14 (33.3) | 34 (54.8) | 1.44 (1.06–1.96) | 0.022 |
| Instrumental | 6 (14.3) | 2 (3.2) | 0.41 (0.12–1.37) | 0.045 | |
| Caesarean section | 22 (52.4) | 26 (41.9) | 0.88 (0.63–1.21) | 0.412 | |
| Epidural/spinal(nulliparous: n=20, multiparous: n=36) | No | 9 (45.0) | 19 (52.8) | 1.19 (0.76–1.65) | 0.577 |
| Yes | 11 (55.0) | 17 (47.2) | 0.82 (0.40–1.66) | ||
| Second degree tear excluding episiotomy excluding episiotomy (nulliparous: n=20, multiparous: n=36) | No | 14 (70.0) | 21 (58.3) | 0.84 (0.57–1.23) | 0.388 |
| Yes | 6 (30.0) | 15 (41.7) | 1.40 (0.64–3.08) | ||
| Episiotomy (nulliparous: n=20, multiparous: n=36) | No | 11 (55.0) | 32 (88.9) | 2.42 (1.05–5.57) | 0.040 |
| Yes | 9 (45.0) | 4 (11.1) | 0.37 (0.20–0.69) | ||
| Third or fourth degree tear (nulliparous: n=20, multiparous: n=36) | No | 18 (90.0) | 36 (100.0) | – | 0.123 |
| Yes | 2 (10.0) | 0 (0.0) | – | ||
| Total blood loss during birth (ml) | Mean ± standard deviatio | 564.6 ± 629.4 | 346.5 ± 157.0 | −218.02 (−383.35–-52.68) | 0.010 |
| Gestational age at birth (weeks) | Mean ± standard deviatio | 39.1 ± 2.2 | 38.7 ± 1.5 | −0.39 (−1.11–0.32) | 0.279 |
| Birth weight (g) | Mean ± standard deviatio | 3208.2 ± 618.7 | 3333.3 ± 614.5 | 125.1 (−119.18–369.35 | 0.312 |
| APGAR score at 5 minutes | Mean ± standard deviatio | 8.6 ± 1.0 | 8.9 ± 0.5 | 0.26 (−0.03–0.55) | 0.074 |
| Gender | Female | 22 (52.4) | 27 (43.5) | 0.87 (0.63–1.20) | 0.376 |
| Male | 20 (47.6) | 35 (56.5) | 1.24 (0.77–1.97) | ||
| Resuscitation after birth | No | 27 (64.3) | 48 (77.4) | 1.33 (0.88–2.00) | 0.143 |
| Yes | 15 (35.7) | 14 (22.6) | 0.70 (0.44–1.11) | ||
| Special care nursery admission after birth | No | 36 (85.7) | 46 (74.2) | 0.77 (0.56–1.06) | 0.158 |
| Yes | 6 (14.3) | 16 (25.8) | 1.61 (0.78–3.32) | ||
| Received infant formula during hospital stay | No | 27 (64.3) | 35 (56.5) | 0.91 (0.65–1.29) | 0.614 |
| Yes | 13 (31.0) | 21 (33.9) | 1.14 (0.68–1.90) | ||
Discussion
This study was conducted to compare the prevalence of fear of childbirth, its risk factors and birth outcomes between nulliparous and multiparous women. Approximately one-third of nulliparous and multiparous women experienced fear of childbirth, with no significant difference between the two groups. Compared with multiparous women, nulliparous women with high to severe fear of childbirth were more likely to have a lower family income, attend antenatal educational classes, have assisted conception and report a higher rate of severe to extremely severe symptoms of depression, anxiety and stress. Comparison of birth outcomes showed that nulliparous women with high–severe fear of childbirth were more likely to receive oxytocin for induction or augmentation of labour and have prelabour cervical ripening, instrumental birth, an episiotomy and a greater volume of blood loss during birth.
Earlier research in Australia (Toohill et al, 2014) showed that almost 32% of nulliparous women and 18% of multiparous women had high levels of fear of childbirth (using W-DEQ cut-off score ≥66). A recent systematic review of 27 observational studies showed that the global prevalence of fear of childbirth is 16% (Sanjari et al, 2021), around half of the prevalence found in the present study. While fear of childbirth is not a novel phenomenon, a growing rate indicates that insufficient attention has been given to resolving this issue. Confounding factors responsible for this phenomenon have not been eliminated, such as the lack of woman-centred care and meaningful involvement of women in the process of decision-making, unfavourable relationships between the clinician and the women and the women's lack of knowledge about the birth process (do Souto et al, 2022; Fielding-Singh and Dmowska, 2022; Leinweber et al, 2023).
Sanjari et al's (2021) review indicated that fear of childbirth was more common in nulliparous women with a diploma or lower education, single/divorced women, and those in the second trimester of pregnancy. Other reasons for a higher level of fear among nulliparous women may include uncertainty about labour pain, support during labour and birth, outcomes and the birth experience. However, conflicting reports from other studies have demonstrated that the prevalence of fear of childbirth can be higher among some multiparous women, potentially as a result of previous negative childbirth experiences (Fenwick et al, 2009; Otley, 2011; Toohill et al, 2014).
The prevalence of fear of childbirth in the present study was twice the global rate reported by Sanjari et al (2021). This discrepancy could be the result of variance in the participants’ cultural background, as most of the present study's participants were from culturally and linguistically diverse backgrounds. A Swedish study (Ternström et al, 2015) reported that being a migrant and giving birth in a new country negatively impacts fear of childbirth, and culturally and linguistically diverse women were three times more likely to experience fear of childbirth during pregnancy than Swedish-born women. Women originally from developing countries have different socioeconomic statuses and health systems, and may have experienced issues such as insufficient spousal support, inability to make decisions about their birth plan, lack of trust in healthcare staff and unavailability of home visits and home birth options (Phunyammalee et al, 2019; Nguyen et al, 2021).
Severe fear of childbirth is a significant public health issue worldwide. Women with severe fear of childbirth may not adapt to and cope with the labour and birth process sufficiently and confidently, and are more likely to experience adverse outcomes (Rúger-Navarrete et al, 2023). The present study showed that the rate of some negative birth outcomes was higher among nulliparous women, such as prelabour cervical ripening, oxytocin use, instrumental birth, episiotomy and greater blood loss. Recent research has suggested that negative birth outcomes are more common among women with fear of childbirth (Rúger-Navarrete et al, 2023). Although the present study did not show any statistically significant differences in the rate of fear of childbirth between nulliparous and multiparous participants, it is important to bear parity in mind when discussing fear of childbirth with a woman, as it may originate from different concerns in nulliparous women compared to multiparous women, for example, as a result of the higher rate of depression, anxiety and stress in nulliparous women.
The higher rates of prelabour cervical ripening, oxytocin use in labour, instrumental birth, episiotomy, epidural/spinal analgesia and greater blood loss in nulliparous women with high–severe fear of childbirth, compared to their multiparous counterparts, has been reported in previous studies. Green et al (2022) reported that, compared to multiparous women, primparous women experienced a higher level of fear during childbirth because of concerns for their health and wellbeing. They also showed that women with negative emptions were more likely to undergo birth interventions. Another study reported that fear of childbirth was a predictor of labour pain intensity, as primiparous women with higher level of fear of childbirth were more likely to receive epidural analgesia (Deng et al, 2021). It has also been reported that higher levels of fear could be related to lower overall childbirth self-efficacy and self-efficacy expectancies in primiparous women (Shakarami et al, 2021).
Strengths and limitations
This study was novel and adds to the body of knowledge on fear of childbirth, including its the prevalence, risk factors and birth outcomes. Previous research on fear of childbirth has mainly focused on nulliparous women. However, the present study recruited both multiparous and nulliparous women to expand the body of knowledge in this understudied population. A comprehensive online questionnaire was used, which investigated several potential risk factors. The FoBS and W-DEQ were used to support the findings on the prevalence of fear of childbirth. Furthermore, the study cohort consisted of an ethnically diverse population that allowed exploration of potential demographic risk factors of fear of childbirth related to this population.
The DASS questionnaire was not completed by all women, despite being a self-reported anonymous online survey and taking only 20 minutes to complete. In addition, labour and birth outcomes were not available for all participants, as some gave birth in other hospitals whose records were not accessible. Furthermore, the study was conducted in a public hospital and did not include data from private hospitals. It may be beneficial for future research to examine the prevalence of fear of childbirth among women in both public and private settings.
Recommendations for practice
With the reported prevalence of fear of childbirth in Australian women in this study, it would appear that hospitals could be better equipped to provide customised maternity care. Providing a comprehensive set of activities to reduce fear of childbirth among pregnant women would be beneficial. The first step is to identify those at risk of severe fear of childbirth and provide timely and proper support to them and their family. The next step is to develop prenatal and antenatal education programmes in maternity facilities to decrease fear of childbirth, supplemented with ongoing postpartum monitoring. It is critical for healthcare providers to understand women's pregnancy journeys. To empower and support women through education programmes, their unique needs must be recognised, and assistance in coping with fear and anxiety must be made available to contribute to a positive pregnancy experience and birth outcome.
Conclusions
The prevalence of fear of childbirth was 33% in nulliparous women and 31% in multiparous women, based on a sample of women from a hospital in Australia. The results suggest that, at high–severe levels of fear of childbirth, nulliparous women were more likely to have a lower family income, attend antenatal educational classes and undergo assisted conception when compared to the multiparous women. Among women who had given birth at the hospital, nulliparous women with high–severe fear of childbirth had a greater likelihood than their multiparous counterparts of having prelabour cervical ripening, oxytocin for induction or augmentation, instrumental birth, episiotomy and greater volume of blood loss during birth. Considering the impact of high fear of childbirth on women's wellbeing and birth outcomes, it is important to acknowledge this concern early during pregnancy and provide timely support so that women can have a positive experience and a smooth transition to motherhood.
Key points
- Australian nulliparous and multiparous women experience similar levels of fear of childbirth.
- Fear of childbirth is associated with several negative birth outcomes in both nulliparous and multiparous women.
- To empower and support women with fear of childbirth, their unique needs must be recognised, and assistance in coping with fear and anxiety must be made available to contribute to a positive pregnancy experience and birth outcomes.
CPD reflective questions
- How can midwives detect fear of birth in pregnant women and what factors should be considered?
- What potential solutions and approaches can be used to resolve fear of childbirth during pregnancy?
- What is the role of a partner when assisting women with fear of childbirth?
- How can fear of childbirth in current pregnancy affect birth outcomes in subsequent pregnancy/pregnancies?