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Acta Obstet Scand 1998; 77: 542-547

Fear of Childbirth during Pregnancy may Increase the Risk of
Emergency Cesarean Section

Elsa Lena Ryding1, M.D.
Barbro Wijma2, M.D., Ph.D., associate professor
Klaas Wijma2, Ph.D., associate professor
Håkan Rydhström3, M.D., Ph.D.


From the Departments of Obstetrics and Gynecology,          1Central   Hospital,
Helsingborg, 2University Hospital, Linköping, and 3University Hospital, Lund,
Sweden


Address for correspondence:
Elsa Lena Ryding, M.D.
Department of Obstetrics and Gynecology
Central Hospital
S - 251 87 Helsingborg
Sweden
Tel +46 42 10 00 00
Fax +46 42 10 22 05


Running headline: Fear adds to risk of emergency cesarean
                                                                     2
Abbreviations:
CS: cesarean section; W-DEQ: Wijma Delivery Expectancy Questionnaire; STAI:
State-Trait Anxiety Inventory; SCI: Stress Coping Inventory; SGA: small for
gestational age; OR: odds ratio; CI: confidence interval.
                                                                                3
Abstract

Fear of Childbirth during Pregnancy may Increase the Risk of
Emergency Cesarean Section

Background. The purpose of our study was to elucidate the association between fear
of childbirth, general anxiety, and stress coping during the third trimester of
pregnancy, and a subsequent delivery by emergency cesarean section.
Methods. In a case-control study, 1,981 Swedish-speaking women completed three
self-assessment questionnaires at 32 weeks' gestation. Ninety-seven of these women
were delivered by emergency cesarean section. Fear of childbirth, general anxiety
and the stress coping ability of these 97 cases were compared with the same features
in 194 controls, matched for age and parity.
Results. Women, subsequently delivered by emergency cesarean section, reported a
greater anxiety and a poorer stress coping ability, and, most obviously, a greater fear
of childbirth at 32 weeks' gestation. After elimination of possible confounders, the
odds ratio for emergency cesarean section was examined for women whose scores
were above various cut-off points according to the fear of childbirth measuring
instrument. For women with a serious fear of childbirth the odds ratio was 3.0 (95%
confidence interval 1.4 to 6.6), and the population attributable risk 0.167.
Conclusion. Fear of childbirth during the third trimester of pregnancy may increase
the risk of subsequent emergency cesarean section.


Key words: fear of childbirth; anxiety; stress coping; pregnancy; emergency cesarean
section
                                                                                 4
The evidence of that maternal stress and anxiety have a deleterious effect on the
outcome of pregnancy is not unanimous (1, 2, 3). The theory that anxiety during
pregnancy can interfere with the delivery process has been supported by some
prospective studies (4, 5, 6, 7). Such interference can occur directly by
psychophysiological pathways. Pharmacologically, epinephrine has been associated
with enervated uterine contractility, and norepinephrine with intensified uterine
contractility (8). Self-reported anxiety during labor was found to be correlated with
the concentration of epinephrine in plasma (9). Longer duration of the second stage
labor has been observed in women with higher catecholamine concentrations (8).
Anxiety can also affect the birth process indirectly, by influencing maternal
behaviour, e.g. by stimulating the urge to smoke. However, a more recent
epidemiological investigation (10) could not demonstrate any relation between
anxiety during pregnancy and non-spontaneous delivery. Women with antenatal
fear of childbirth have also been found to run an increased risk of dissatisfaction with
their delivery experience (11). They also tend to have an increased rate of cesarean
section (CS) and operative vaginal delivery (12).
   According to Barlow (13), anxious apprehension is "an unpleasant affective state
associated with perceptions of future unpredictability and uncontrollability". When a
person with a specific anxiety has to face the feared situation, there is an increased
physiological arousal. There is also an attentional narrowing with a heightened
perception of threat-related stimuli. As a result the worry is felt more intensely. The
person's performance is then often dysfunctional, which further aggravates the
situation. Applied to obstetrics, this could mean that the specific anxiety is fear of
childbirth (14) and the feared situation, labor. Increased physiological arousal may
affect the uterine function and, due to attentional narrowing, the woman in labor
perceives most events as threat-related stimuli. An example of the consequence of
such intensified worrying, dysfunctional performance and worsened situation is the
difficulty of establishing a good rapport between the obstetrical staff and very
anxious parturients. It then becomes difficult to offer help in a way which is
acceptable.
   Thus, maternal anxiety may be correlated with uterine dysfunction, such as hypo-
or hyperactive contractions, and with dysfunctional performance during labor. It can
be hypothesized that anxiety and, specifically, fear of childbirth, as well as a
diminished ability to cope with stress, imply an increased risk of intrapartum
complications, such as prolonged labor or fetal asphyxia. An emergency CS is then
sometimes considered the safest way to conclude a complicated delivery.
   The aim of this case-control study was to assess the association between fear of
childbirth, general anxiety, and stress coping during the third trimester of
                                                                                    5
pregnancy, on the one hand, and a subsequent delivery by emergency CS on the
other.



Material and methods

From 1st January, 1992 to 28th February, 1993, most women at 32 weeks' gestation,
intending to give birth at Helsingborg Central Hospital, were invited to participate
in the study. Practically all pregnant women living in this catchment area of about
38,000 females aged 15-44 years give birth at the same unit. The frequency of
emergency CS delivery during the study period was 6.3% in Helsingborg, and the
overall CS rate, 9.1%.
   Swedish-speaking women attending the antenatal program at all nine antenatal
clinics in the area, at three of the private gynacologists in the city, or at the hospital's
clinic for complicated pregnancies, were eligible for the study with the following
exceptions. A few women who subsequently did not give birth at Helsingborg
Hospital were excluded, as also were 3 women who received specific treatment for
their fear of childbirth. Women scheduled for an elective CS were also excluded, as
they were at risk for an emergency CS only during a limited time of their pregnancy.
The remaining group, eligible for the study, comprised 2,361 women out of a total
population of about 2,700 pregnant women during the study period. The majority of
those excluded could not speak, read or write Swedish.
   The women completed the questionnaires at the antenatal clinics. The midwives
arranged for the women to sit in seclusion for about 30 minutes, during a visit as
close as possible to 32 complete gestational weeks. A total of 1,981 women (84%)
completed the questionnaires. The mean age of the whole sample was 28 years
(range 16-43). Altogether 380 eligible Swedish-speaking women did not participate,
206 due to organizational failure, while 174 declined. The midwives and physicians
caring for the women during pregnancy and labor had no access to information
contained in the questionnaires.
   Nineteen of the 378 drop-outs (5%) were delivered by emergency CS, as were 97
participants (4.9%). These 97 constituted the case group. Their mean age was 29 years
(range 19-43); 60% of them were nulliparous. A control group of 194 women matched
for age and parity (nulli- or multiparity) were selected from among the remaining
participants. Obstetrical data were collected from the antenatal and hospital records.
   The psychological measures consisted of the following questionnaires: The Wijma
Delivery Expectancy Questionnaire (W-DEQ) (15), the State-Trait Anxiety Inventory
(STAI) (16), the Stress Coping Inventory (SCI) and a demographic questionnaire.
                                                                                   6
  The W-DEQ version A measures fear of childbirth as operationalized by the
cognitive appraisal of the approaching delivery. The 33-items graphic self-
assessment rating scale has six scale steps per item, ranging from "not at all" to
"extremely" with a minimum score of 0 and a maximum of 165. A score exceeding 84
was found for 10% of the entire sample (n=1,981) at 32 weeks' gestation. The women
who scored above 84 were considered to be suffering from serious fear of childbirth.
   The STAI measures trait and state anxiety. The version of STAI used in this study
is the part measuring trait anxiety (20 items with four scale steps per item) by means
of an instruction referring to the situation during the current pregnancy.
    The SCI measures stress-coping. It is a recently developed research measure of the
individual's appraisal of her adaptive resources for dealing with stressful situations.
When filling in the SCI, the subject is instructed to rate on a six-point Lickert scale
her personal perception of how often she is able to cope with 41 stressful situations.
The five points are marked with "almost always", "very often", "occasionally",
"rarely" and "never". Thus the minimum possible score is 41, and the maximum, 246.
The higher the score, the greater is the stress-coping ability. The reliability of the SCI
was assessed in a group of pregnant women (N=227) with the following results:
Chronbach's alfa = 0.94; split-half correlation corrected with Spearman-Brown
prophecy formula = 0.93. The correlation between SCI and STAI in the same group
was 0.48. The correlation beween SCI was 0.25.
   Possible confounders were identified from background data. These included
education, marital status, height and weight before pregnancy as well as obstetrical
risk factors such as serious complications of pregnancy, twin pregnancy, history of
previous emergency CS, history of infertility more than 2 years, and smoking during
pregnancy. Women who smoked only on "special occasions" were classified as non-
smokers, but both light and heavy smokers as smokers, since there was so few light
smokers (less than 10 cigarettes a day). Educational level was reported as 1) <9 years
of elementary schooling, 2) 9 years of elementary schooling, 3) senior high school, or
4) college/university education. The infants were classified as small for gestational
age (SGA) if their birth weight was <mean weight -2 SD according to the
Scandinavian Standard (17).
   Statistical analysis was performed by means of unpaired t-test for continuous
variables and Chi-square test (or Fisher's exact test in the case of small numbers) for
categorical variables. Statistical significance was defined as p < or = 0.05, and odds
ratios (OR) with 95% confidence intervals (CI) are presented.
   The study was approved by the regional committee for ethics in science.
                                                                                7
Results

Table I shows the two groups in relation to certain demographic and obstetrical
variables. Alcohol consumption was also recorded, but was invariably denied
(except for drinking on rare occasions). On the basis of these findings the women in
the case group could be characterized as having a higher prepregnant weight, more
often having a history of infertility and previous emergency CS, and an increased
rate of twin pregnancies, pre-eclampsia, and SGA babies.
   The cases and controls differed concerning their scores in the three psychological
questionnaires (Table II), but most significantly regarding the intensity of fear of
childbirth as measured by the W-DEQ. Therefore, the relative risk, estimated by OR
for emergency CS was examined for women who scored above various cut-off points
in the W-DEQ, in comparison with the rest. The results are shown in Fig. 1. The mean
W-DEQ score for the entire sample (n=1,981) was 54.1+21.1 for nulliparous women
and 57.7+22.1 for parous women.
   The variables characterizing the women in the case group (Table I) were regarded
as possible confounding factors only if they were (i) known risk factors for delivery
complications leading to emergency CS, (ii) might be correlated with fear of
childbirth, and (iii) had already been present at 32 weeks of pregnancy. Prepregnant
weight was considered a factor that was not likely to be related to fear of childbirth,
nor was it in fact correlated to the W-DEQ score. Smoking during pregnancy is a
known risk factor for childbirth complications, but since the women in the control
group smoked about as often as those in the case group, it was not considered to be a
confounder in the present study. Possible confounding factors present from early
pregnancy were: a history of infertility, a previous emergency CS, and a twin
pregnancy (diagnosed during the first 17 weeks of pregnancy). Even when those 26
women with one or more of these variables were excluded from the analysis,
together with their 52 controls, the W-DEQ scores remained about the same
(64.0+20.6 vs 53.9+20.2). The OR for emergency CS for women who scored above
various cut-off levels in the W-DEQ in comparison with the rest, were recalculated
and found to be about the same as the results of the original material. These 26
women were therefore replaced in the analysis.
   The records of those women who had pre-eclampsia or hemorrhage during
pregnancy, false labor leading to hospitalization, or an SGA baby were then carefully
scrutinized. Exclusion from the analysis was made only when a complication was
already recorded at the time when the woman completed her questionnaire.
Accordingly, 9 women were excluded together with their 18 controls. The W-DEQ
                                                                                  8
scores remained about the same (64.7+21.5 vs 54.1+20.2). The OR for emergency CS
was re-examined. The results are shown in Fig. 1.
   Thirty women were considered to have a serious fear of childbirth, with a W-DEQ
score exceeding 84. OR for emergency CS was 3.5 (95% CI 1.6 to 7.3) in comparison
with women who scored less. After exclusion of those 2 women who must have
known about the serious complications of pregnancy (one early pre-eclampsia and
one IVF pregnancy with haemorrhage) the OR for emergency CS was 3.0 (95% CI 1.4
to 6.6), and the population attributable risk, 0.167. Compared with the women with a
lower W-DEQ score, these 28 women also had a higher general anxiety level (mean
sum score of STAI 45.5+20.3 vs 33.5+8.6, p<0,0001) and a lower stress tolerance
(mean sum score of SCI 161.4+23.8 vs 177.8+20.9, p<0,0001). There was a tendency
for smoking to be more common (46% vs 27%, NS) among the women with a serious
fear of childbirth, but they did not differ from the rest of the subjects with respect to
any of the other variables studied.
   Sixteen of those women with a serious fear of childbirth belonged to the case
group after the exclusion of women who may have known about pregnancy
complications when completing the questionnaire. Imminent fetal asphyxia was the
main indication for emergency CS in 69% of those women, compared with 39% of
those women without a serious fear of childbirth (p<0.05). Protracted delivery was
the main indication for emergency CS in 13%, compared with 21% of the women
without a serious fear of childbirth (NS).
   Imminent fetal asphyxia or placental abruption was the main indication for
emergency CS in 48% of all those women who were smokers, compared with 47% of
all the non-smokers (NS). Thirty-nine women were operated because of imminent
fetal asphyxia. Within that group, 4 out of 11 women with serious fear of childbirth
smoked. Eight out of 28 women without serious fear of childbirth smoked. No
correlation was found between smoking and serious fear of childbirth within the
asphyxia group.



Discussion

The results of the present investigation suggest an increased risk of emergency CS
when a pregnant woman suffers from serious fear of childbirth. Study of those
suffering in this way has revealed a picture of patients in need of special antenatal
care. Their high level of general anxiety and low stress tolerance may inhibit their
postpartum adaptation process. They are also more likely to be dissatisfied with their
delivery experience (11), which can provoke posttraumatic stress reactions (18, 19) or
                                                                                9
other emotional distress postpartum (20, 21, 22, 23). Imminent fetal asphyxia was the
chief reason for emergency CS in this group, but whether or not this was related to
anxiety, exemplified by maternal smoking, hyperventilation during labor,
hyperactive uterine contractions, or some other hitherto unknown factor, was not
ascertained in this study which focused on antepartum variables. The results do not
support the theory that fear causes hypoactive uterine contractions or that it
prolongs labor. Since there were few women with serious fear of childbirth
subsequently delivered by emergency CS, these results must be regarded with some
degree of caution.
   If, hypothetically, all cases of serious fear of childbirth could be eliminated, the
results of the present study would indicate a possibility of reducing the number of
emergency abdominal deliveries at our hospital by 16.7%. Thus, to diagnose and
treat fear of childbirth in pregnant women ought to be an important task for
antenatal programs. Increased awareness of the problem could help midwives to
identify those pregnant women who need special care. Determination by means of
the W-DEQ, if further developed for diagnostic purposes, might be a practicable way
to identify these women. The questionnaire, which takes 5-10 minutes to complete,
provides an objective estimate of the degree of women's fear of childbirth. It has been
suggested that serious fear of childbirth can be treated (24, 25, 26, 27), but the
effectiveness of treatment programs remains to be evaluated. In our opinion, elective
CS necessitated by fear of childbirth (28) can be restricted to serious cases not
amenable to treatment.
   Our study sample is believed to be representative of the total population of
pregnant Swedish-speaking women in the Helsingborg area. To perform a case-
control study instead of analysing the entire material was considered the most cost-
effective course. Analysis of the entire cohort might well have added to the
information.
   The decision to regard a W-DEQ score of >84 (the 10% level of the total sample of
1,981 women) as an indication of serious fear of childbirth was dictated by the need
for a suitable number of women, belonging to a clinically relevant category, in the
analysis. Areskog et al. (29) found that 6% of Swedish women during late pregnancy
suffered from a disabling fear of childbirth, while 17% felt a more moderate but still
troublesome fear.
   Objections could be raised against our way of examining the possible confounding
factors. For instance, as smoking was about as common in the case group as among
the controls, the smokers were not excluded, in order to retain a reasonable number
of women in the analysis. However, the women most seriously afraid of childbirth
did tend to smoke more often than the others, although there was no evidence that
                                                                                  10
smoking per se affected the rate of emergency CS, or the prevalence of imminent fetal
asphyxia and placental abruption, in those women. Because so few women had a
serious fear of childbirth, the effect of smoking is difficult to assess in this particular
group.
   The causes of fear of childbirth (25) were not the subject of the present study. It is
conceivable that suspected complications of pregnancy at 32 weeks' gestation may
have influenced the measurements in some women who later did not receive any
diagnosis of serious pregnancy complication in their records. Because such
suspicions cannot have been an indication for emergency CS, they were not
considered to be confounding factors.
   Stress coping was measured by means of a newly devised questionnaire. Such a
questionnaire may be of limited value. Moreover, women less able to cope with
stress, but without any specific fear of childbirth, may feel less anxious during labor,
as they do not regard delivery as a particularly stressful event. This may explain why
the SCI score has a weaker correlation with the emergency CS rate than has the W-
DEQ score.
   Among the questionnaires utilized, the STAI is the best known. Previous studies
using the STAI during pregnancy and intrapartum (6, 8, 30) have demonstrated
positive correlations between state-and-trait anxiety and duration of labor. In the
present study the association between maternal anxiety, as measured with the STAI,
and subsequent emergency CS was weaker than the association between maternal
fear of childbirth and subsequent emergency CS, as measured with the W-DEQ.
Anxiety-prone women not specifically apprehensive about childbirth may be better
prepared when facing labor and delivery. This would explain the absence in one
prospective population study (10) of any effect of antenatal anxiety on non-
spontaneous delivery. In that study, Perkin et al. used the General Health
Questionnaire, which measures maternal anxiety in general, rather than specific fear
of childbirth. Perkin's study included instrumental and breech vaginal delivery and
elective CS, besides emergency CS.
   In conclusion, it is possible that fear of childbirth during pregnancy may increase
the risk of subsequent emergency CS. To establish whether accurate diagnosis and
effective treatment of fear of childbirth might reduce the emergency CS rate is an
urgent topic for research.
                                                                     11
Acknowledgement

This study has been aided by research grants from the Stig and Ragna Gorthon
Foundation and from Östergötland County Council.
                                                                              12
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                                                                           16
Table I. Socioeconomic and obstetric characteristics of women delivered by
emergency cesarean section (cases) and a control group of women matched for age
and parity.
________________________________________________________
Variable                        Cases              Controls
                                (n=97)      (n=194)
________________________________________________________
Prepregnant weight (kg)
mean +SD                          66.1+10.6        62.9+9.4         p<0.01

Mother's height (cm)
mean +SD                        165.0+6.4            167.1+6.2        NS

Gestational age at
delivery, mean +SD               39.1+2.0            39.3+1.3         NS

Education level, mean +SD         3.1+0.7            3.2+0.6          NS

Smoking during
pregnancy, n (%)                  29 (30%)           52 (27%)         NS

Living alone, n (%)               4 (4%)             7 (4%)           NS

Infertility >2 years, n (%)      11 (11%)            10 (5%)          NS

Emergency CS
previously, n (%)                13 (13%)            6 (3%)           p<0.01

Twin pregnancy, n (%)             5 (5%)               0              p<0.01

Pre-eclampsia, n (%)               16 (17%) 2 (1%)         p<0.0001

Haemorrhage, pregnancy n (%)       3 (3%)            2 (1%)      NS

False labor, n (%)                 3 (3%)            2 (1%)      NS

SGA baby, n (%)                       13 (13%) 7 (4%) p=0.01
________________________________________________________
Level of education, see Material and Methods
                                                                                         17
Table II. Group sum scores in W-DEQ, STAI and SCI at 32 weeks' gestation of women subsequently
delivered by emergency cesarean section (cases) and a control group matched for age and parity


              Cases         Controls      Mean          CI            p-values
              n=97          n=194         difference
___________________________________________________________________________

W-DEQ 64.6 +22.2      54.3 +19.8      10.3         5.3 - 15.3           p< 0.0001
mean+SD

STAI          36.7 +13.6      34.0 +9.1      2.7            0.1 - 5.3          p< 0.05
mean+SD

SCI           172.4+21.5    177.4+21.6     5.0       -0.3 - 10.3      p= 0.05
mean+SD
___________________________________________________________________________
                                                                      18
Fig. 1. OR for emergency cesarean section for women who scored above
vis-á-vis below various cut-off levels in the W-DEQ at 32 weeks of
pregnancy, with 95% CI. -------- = total material. -------- = after exclusion
of those 9 women (and their 18 controls) who may have known about
complications of pregnancy already when completing the questionnaire.