There is no agreed definition on what fear of birth (FoB) is, largely due to the differences in its diagnostic testing (Haines et al, 2011). However, Areskog (1982: 263) defined severe FoB in women who ‘expressed a strong anxiety which had impacted their daily functions and wellbeing’.
Prevalence
The evidence for a true prevalence of FoB is scarce; however, between 7 and 26% of women in high income countries fear childbirth (Hofberg and Ward, 2004; Laursen et al, 2008; Kjærgaard et al, 2008; Fenwick et al, 2009) with 6% reporting the fear as ‘disabling’ (Searle, 1996).
History
A FoB was documented as early as 1858 by French psychiatrist, Marcé (Hofberg and Brockington, 2000: 83):
‘If they (women) are primiparous, the expectation of unknown pain preoccupies them beyond all measure, and throws them into a state of inexpressible anxiety. If they are already mothers, they are terrified of the memory of the past and the prospect of the future.’
Marcé specifically addressed fear of pain as the predominant concern of 19th Century pregnant women whereas more recent studies (Pleshette et al, 1956; Light and Fenster, 1974) reported that the two most common fears/anxieties of women were: fear of losing their babies and their babies having congenital abnormalities. Swedish obstetrician, Areskog reported that women were also fearful of physical damage to both themselves and their babies during birth (Areskog et al, 1982).
In the UK, Hofberg and Brockington (2000) articulated FoB in the literature by adopting the term ‘tocophobia’; derived from the Greek, ‘tocos’ (birth) and ‘phobia’ (fear). The psychiatrists published a review of 26 case studies of women referred to them with FoB. Consequently, they developed two diagnostic terms, ‘primary tocophobia’—affecting nulliparous women and ‘secondary tocophobia’—characteristic in multiparous women (Hofberg and Brockington, 2000). Others have reported that primigravidas fear the unknown aspects and pain of childbirth along with parenthood itself (Saisto and Halmesmäki, 2003). Secondary tocophobia was reported in women with a history of traumatic birth or poor perinatal outcome (Hofberg and Ward, 2004). Størksen et al (2013) reported that negative birth experiences and/or previous traumatic births increased the risk of FoB in subsequent pregnancies five-fold.
In the UK, FoB has been increasingly cited as a reason for elective caesarean sections (Nieminen et al, 2009) and increased rates of psychological morbidity have been reported in those women where caesarean section requests for FoB were declined (Wiklund et al, 2007). The full impact of FoB on elective caesarean section rates is relatively unknown; however, the overall trend of increased caesarean section rates in the UK has prompted national guidance (National Institute for Health and Care Excellence (NICE), 2011). With reference to FoB, NICE (2011: 100) specifically recommended that women expressing a FoB should be offered elective caesarean section and state:
‘The most important outcomes to consider were the women's birth experience along with the women's satisfaction and experiences of care’.
This acknowledges the potential impact on the mental health of women and their subsequent long-term needs. However, the guidance also addressed the possible impact on planned caesarean section rates for women with FoB. Thus, women requesting a caesarean section for FoB should be offered specialist support from health professionals within a perinatal mental health pathway. In this context, NICE (2013: 3) define the health professional as:
‘Someone, usually from the maternity team, who has an interest and expertise in providing support to women with higher than normal anxiety levels, to the extent that they are requesting a caesarean section.’
There is limited evidence of expertise in respect of FoB within the maternity services and where expertise exists, it has not been fully evaluated (Gutteridge, 2012). Recommended interventions for women with FoB have included: the provision of dedicated clinics for women requesting caesarean sections and referral to a psychologist/mental health professional. Here, women might discuss factors associated with FoB, e.g. traumatic birth experiences or be assessed for pre-existing mental health disorders (NICE, 2011). However, despite such recommendations, the full significance of such interventions is unknown.
One of the main recommendations by NICE was the provision of intensive midwifery support for women with FoB (NICE, 2011); however, ‘intensive’ was not defined. It is recognised that one-to-one support may make a difference for women who are afraid of childbirth. For example, a recent systematic review on one-to-one care in labour reported fewer epidurals, fewer assisted births and fewer episiotomies when care was delivered by midwives compared with shared care (Sandall et al, 2013). Although women with FoB were not identified in the review, it is conceivable that the one-to-one midwifery-led model could positively influence care for this group of women.
It has been discussed that in spite of national UK guidance (NICE, 2011), there are no contemporaneous data on the scope of service provision for women with FoB. This is compounded by a lack of data on the prevalence of FoB in the UK and by the lack of a consensus on what constitutes FoB. Hence it is important to establish current UK service provision for women with FoB as such information can provide data on the prevalence of FoB and inform the direction of service provision.
Therefore, a national online survey was developed, which was, in part, informed by the recommendations for women with FoB in the NICE (2011) guidelines on caesarean sections. A key consideration was the lack of evidence regarding the existence and effectiveness of current service provision for women who experience FoB; thus, the survey aimed to elicit information within three specific goals:
Methods
Following an online pilot of the tool and in concurrence with Madge and O'Conner (2004), the survey was conducted in two parts in order to reduce respondent fatigue. Part one of the survey posed questions in relation to Trust demographics and the identification of clinical service leads; questions funnelled from the generic to the specific, e.g. the size and location of the maternity unit prior to discrete health professional involvement. Part two of the survey was dedicated to service provision, e.g. guidelines/policies on practice for women with FoB, including any user information.
Each part of the survey consisted of eight questions, which were predominantly closed; however, free text options were included where participants chose the response option, ‘other’. Thus, participants were able to clarify their responses in more depth.
Development
A fundamental feature of any online survey is in the design and delivery of the tool; it must be easy to follow as difficult/ambiguous questions increase the rate of non-completion (Fan and Zheng, 2010).
In an attempt to minimise survey ambiguity, a pilot was conducted across two large university teaching hospitals that were comparable in terms of births per year (5000) and demographics of the population they served (diverse ethnic and social mix).
The pilot survey included six midwives per hospital with varying roles, these included: clinical governance midwives, consultant midwives, midwife specialist roles in information technology and midwives working across clinical bands 5/6. As a result of their comments, questions were rearranged to improve the flow of the survey, e.g ‘place of work’ was changed to ‘please confirm the region in which your place of work resides’. Changes were made as it was felt that this particular question could lead to improvements in the identification of hospital/service providers.
Sample
The survey was undertaken over 9 weeks from July 2013–September 2013. All 202 maternity units in the UK (England, Northern Ireland, Scotland and Wales) were sent the weblink to the survey with a covering electronic letter. Heads of midwifery (HoMs) were targeted in order to maximise response rates; email addresses were confirmed by the local supervising authority midwifery officers (LSAMO). The cover letter included: an explanation for the study, full details of the survey and contact details of the academic institution. Initially, a 6-week time period for the completion of the survey was included but, this was extended to 9 weeks to improve response rates.
Data collection
Data were collected and managed within the data collection facility of the online survey website (surveymonkey.com). The survey was sent out at the beginning of July 2013; response rates were audited on a weekly basis. Initially, response rates were encouraging; week 2 (n=60), week 3 (n=69), week 4 (n=75). The survey was conducted over the summer; therefore, an email reminder was sent to all HoMs at week 6. However, the reminder was marginally effective so LSAMOs were informed of the study and their support was requested. This resulted in an increased response rate and the survey closed after 9 weeks; response rates were:
Data analysis
Data were recorded using the data facility in Survey Monkey and descriptive analysis is presented in tables. Content reported in the free text boxes is reported verbatim; there were insufficient data to perform a content analysis.
Ethics
As this was an audit of FoB services using the Survey Monkey tool, ethical approval was not required; however, the ethical principles of confidentiality and anonymity were applied and all data were anonymised. In addition, principles of data collection/storage were adhered to (Data Protection Act, 1998) along with specific reference to the use of internet data (Markham and Buchanan, 2012).
Results
Part one achieved a 63.4% (n=128) response rate and part two, a 54.4% (n=110) response rate. Specific response rates achieved were as follows: HoMs 39% (n=46), consultant midwives 24% (n=31); others included: professors of midwifery, midwifery managers, audit/research midwives and hospital midwives.
Almost half of the units reported more than 5000 births per year and the number of units offering specialist services for women with a FoB was 52% (n=58). Of these, 31.8% (n=35) used midwifery-led clinics, 16.4 % (n=18) used obstetric-led clinics and only 4.5% (n=5) used specialist psychology clinics.
Women were also referred to a range of specialist services: psychotherapist (n=2), specialist bereavement midwife (n=1), public health midwife (n=1); supervisor of midwives (n=5); midwifery counsellor (n=1), birth options clinic (n=1), consultant midwife (n=4) maternity unit counsellor (n=1), perinatal mental health nurse team (n=2) and a hypnobirthing/listening service (n=1). A further three respondents reported that their service provision was undergoing development/improvement.
Lead providers of the service
Units were surveyed on which health professionals were involved in the care of women who had FoB (Figure 1). Obstetricians were the lead professional in the majority of units (n=106); however, several others were identified, these included midwives (n=17), supervisors of midwives (n=13), perinatal/mental health team (n=8), community midwives (n=7) and a midwifery manager (n=1).
The respondents also included a further array of responses, some examples were: midwifery listening services, holistic therapists, health counsellors, healthy minds strategy, childbirth counsellors, midwives specialising in neonatal hypnotherapy and midwifery managers with interest in psychotherapy/counselling.
While consultant obstetricians were identified as the lead professional. The next question asked respondents to clarify which health professional has the most involvement in the care of women (Figure 2). Midwives were identified as the lead professional responsible for the delivery of care to women. Midwifery titles included: midwife (n=11), community midwife (n=8), supervisor of midwives (n=5), case-loading midwife (n=2), listening service midwife (n=1), unit counsellor and midwife (n=1), specialist midwife counsellor (n=1), parent-craft midwife (n=1), midwife psychotherapist (n=1); public health midwife (n=1), named midwife (n=1); midwifery manager (n=1), consultant midwives (21.4%; n=27), consultant obstetricians (25.4%; n= 32), closely followed by psychologists (6.3%; n=8) and finally, a psychiatrist (0.8%; n=1 0.8%).
Midwifery service provision for women with FoB
Units were specifically surveyed on whether they used designated midwives to care for women with FoB (Figure 3). The majority of respondents, 68.8% (n=88), indicated ‘no’, they did not use designated midwives compared with less than 30% responding ‘yes’ (n=38); two respondents were unsure. Those responding ‘yes’ were asked at what point the midwife had contact with women. The majority of contact occurred in the antenatal period (72.2% (n=40)); 30.9% (n=17) of respondents reported having contact with women in the intranatal period, and 41.8% (n=23) in the postnatal period. Ten respondents, 18.2%, delivered care in the preconception period.
Information for women with FoB and evaluation of services
The survey included a question on the provision/type of information offered to women with FoB. A total of 55% (n=61) did not provide any information or support for women, 32.7% (n=36) provided verbal information, 24.5% (n=27) offered specialist antenatal care, 20% (n=22) provided written information and 15.5% (n=17) offered antenatal education.
Some midwives gave clear examples of their role:
‘If referred to me, I will spend in excess of an hour discussing fears and also reviewing last birth if [there was a] birth before. Care is individualised and I might also work in conjunction with mental health team and on occasions, a psychologist. Sometimes I will meet women more than once, accordingly. Sometimes, it also includes a visit to the birth centre and or delivery suite. If the woman has a booked caesarean section that she is fearful of, I try to ensure that I have spoken to the midwife who will provide care. At times, I have involved the aromatherapist specifically, though aromatherapy is on the birth centre. I also recommend hypnobirthing because many women come back to me to tell me how it really helped them.’
Other examples cited were: counsel-line, cognitive behavioural therapy and three respondents mentioned hypnotherapy.
As care pathways can influence the provision of care, units were surveyed on the provision of information/guidance on FoB for staff. The majority, 78.2% (n=86) stated that they did not have any information for staff, 17.3% (n=19) had guidance in the form of policies and/or guidelines or pathways and 4.5% (n=5) did not know. Copies of guidance were requested and two respondents provided clear examples: a flow chart and a flow chart along with a guideline for women requesting an elective caesarean section. Four respondents also stated that they used a screening tool (not provided) to diagnose women with FoB while a further four indicated guidance was under development.
Finally, units were asked how they evaluated service provision for women with FoB. In 40% (n=44) of cases, no evaluation had occurred. A further 40% (n=44) stated that evaluation of services was not applicable. However, 19% (n=21) had undertaken audits on service provision; one unit involved consumers on a discussion forum.
Discussion
Overall, the final response rate was good (63.4%) especially as online surveys do not achieve the same response rates as paper methods (Nulty, 2008). This study's response rates compared more favourably with two previous online surveys of UK maternity units conducted by McMunn et al (2009) and Cooke et al (2011) who achieved a 30% and 31% response rate, respectively.
Over half of the units reported in this survey offered specialist services for women with FoB; these units may have been more likely to respond to the survey, thus influencing the rates. However, it was clear that women accessed a wide range of professionals including specialist midwives and psychotherapists. In spite of midwives being identified as having the most involvement in the care of women with FoB, women were most likely to be referred to consultant obstetricians. This could be as a direct consequence of Scope of Practice implications, as midwives in the UK have a legal duty to refer women with deviations from the normal to a medical practitioner (Nursing and Midwifery Council (NMC), 2012). Furthermore, although not all women with FoB seek an elective caesarean section there is provision within the NICE (2011) guidelines that women with FoB requesting a caesarean section should be referred to an obstetrician. Hence, the respondents might be reflecting a generic compliance with national guidelines in this respect. There is a general trend towards shared decision-making and women-centred maternity care (Carter et al, 2010) hence from a compliance prospective, this might have influenced the involvement of obstetricians where a request for caesarean section ensued.
The survey also revealed that overall, more midwives across a range of roles and services were involved in the care of women with FoB. This is important as the first point of contact for all pregnant women is the midwife. It also appears that senior midwives (e.g. consultant midwives, supervisors of midwives) and HoMs are involved in the care of women with FoB. This is also crucial, as midwives employed in such senior roles have the capacity to drive midwifery care pathways forward. It was also interesting to note that despite FoB being recognised as a psychological disorder (American Psychiatric Association, 2000), psychologists/psychiatrists were rarely reported as being involved in the care of women with FoB. A possible explanation might be the lack of funding for psychological support for women during pregnancy; for example, the same reason for lack of implementation of national guidelines on antenatal/postnatal mental health (NICE, 2007). Or, it may be that some respondents are not aware that such services might be available to them.
Finally, it was noted that over half of the units did not provide any information for women with FoB. Hence, although outside the scope of this survey, those maternity units providing information could be further explored in order to identify areas of good practice.
Conclusion
The survey revealed that 47.3% (n=52) of maternity units provided no specialist services for women with FoB. Those units offering provision to women with FOB varied, e.g. specialist midwifery clinics, specialist psychological services or referral to consultant obstetricians. Finally, the survey found that care pathways and services for women with FoB have not been widely implemented in the UK and in those units which have guidance, very few units have evaluated them. There is a huge variation in services offered to women with FoB. Until we know more about FoB, it maybe premature to recommend that units provide additional services. Moreover, such services should be fully informed and rigorously evaluated.