Labour & Birth

The fear factor why are primigravid

women fearful of birth?
Alison Brodrick

ORIGINAL
For some women a fear of childbirth can overshadow their whole pregnancy. Many of
these women will have experienced a previous negative or even traumatic birth which has
triggered or exacerbated the fear (Saisto et al 1999, Rouhe et al 2009, Strksen et al 2012).
In a primigravid population this is not the case and understanding the roots of the fear
acquisition is both interesting and challenging. As health care professionals it is important
that we seek to understand and address ways of reducing fear and find ways of supporting
women to feel confident in their ability to navigate the journey to motherhood.
This article outlines the role played by the cultural framing of birth and how it impacts on
the beliefs and fears of primigravid women. Maternal characteristics and personality traits
are also explored and how as health care professionals we can support primigravid women
who present with a primary fear of childbirth.
Key words: Fear, anxiety, primigravida, childbirth, self-efficacy, caesarean section

Introduction
It is generally accepted that fear of childbirth affects
about 20% of women and that 610% of women
experience a severe fear of childbirth (Saisto &
Halmesmaki 2003). Studies suggest that it is more
common amongst nulliparous women than parous
women (Zar et al 2001, Rouhe et al 2009).
There is considerable evidence linking a previous
negative or traumatic birth experience with an
increased fear in subsequent pregnancies (Saisto et al
1999, Rouhe et al 2009, Strksen et al 2012,). The
presence of fear in this group seems logical, they have
had exposure to an event that has caused emotional
trauma and possibly physical trauma. This can be
linked to tangible events such as medical problems
and unexpected complications in labour (Areskog et
al 1982, Rouhe et al 2009, Strksen et al 2012). The
fact that women encounter obstetric problems is not
however predictive of fear in subsequent pregnancies
in Strksen et als (2012) study, 80% of women
who experienced obstetric complications did not
view their birth as negative and did not develop a
fear of childbirth. This leads us to consider the more
subjective elements, including the attitudes of the
staff delivering care and the perceived level of support
in labour, both of which can have a huge impact on
how a woman views her birth experience and both
MIDIRS Midwifery Digest 24:3 2014

correlate with a negative birth experience when they

are perceived as missing from care (Fisher
et al 2006, Fenwick et al 2009). The other important
contributors are a perceived lack of control in labour
(Green et al 2003, Waldenstrom et al 2004) and a gap
between a womans prenatal expectations of labour
and birth and reality (Gibbins & Thomson 2001).
In a primigravid population this previous lived
experience does not exist, yet for some women the
fear of experiencing vaginal birth is so strong it will
lead to termination of the pregnancy (Hofberg &
Brockington 2000), and for those that continue it
may result in a maternal request for caesarean section
(CS) (Rouhe et al 2009, Fenwick et al 2010, Strksen
et al 2012), thus avoiding having to deal with the fear.
Unnecessary abdominal surgery as a way of avoiding
a normal physiological event has a significant impact
on public health with risks to both mother and
baby (Villar et al 2006, Liu et al 2007), not just in
the current pregnancy but escalating in subsequent
pregnancies and births (Jackson & Paterson-Brown
2001, Gray et al 2007).
Primigravid women often fear the unknown and a
loss of control (Strksen et al 2012). Whilst their fear
generation has taken a different route from parous
women, their fears are similar with pain and coping
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with pain a predominant feature (Saisto et al 1999,

Melender 2002). Another area that is important to
consider is a history of sexual abuse which is also
linked to a fear of childbirth (Heimstad et al 2006);
midwives need to bear this in mind when a woman
vocalises a fear of birth.

The effects of cultural socialisation on fear of

childbirth
What is shaping this fear in nulliparous women is
complex and multi-factorial. In terms of context it is
useful to explore how society as a whole views birth
and how those perceptions are formed.
In terms of understanding how attitudes to childbirth
are changing in the UK, Green et als (2003) large
prospective study is insightful. Comparing results
from 1997 and 2000, the study illustrates increasing
anxiety around the process of childbirth with more
women fearing the pain of labour, more women
wanting to have an epidural and fewer women
planning a natural birth. It also highlighted an
increased acceptance of intervention in the childbirth
process. Other studies too have highlighted the
interplay of societal norms, especially seen in the
tolerance of rising CS rates coupled with the view
that vaginal birth is risky and therefore CS is the
alternative (Fenwick et al 2010, Haines et al 2011).
CS is seen as an acceptable way for a baby to enter
the world; rather than seeing labour and birth as
a journey it is considered a way of getting a baby
(Fenwick et al 2010).

A favourable attitude towards obstetric intervention

was also found in Stoll et als (2014) recent study
which examined Canadian students view of birth.
Students who relied on the media alone as a source
of knowledge concerning childbirth had the highest
level of fear and were twice as likely to prefer a CS
when compared with students who cited a variety of
sources. The powerful effect of the media and listening
to horror stories has been cited in other studies
exploring an increased fear amongst primigravid
women (Saisto & Halmesmaki 2003, Sercekus &
Okumus 2009).There is also some evidence that a
perceived poor family history of childbirth, especially
how mothers relate their own birth experiences to
their daughters, will lead women to believe that there
is a heredity factor that makes vaginal birth risky
and something that they should avoid (Wiklund et al
2007).
These outside sources of information have the
potential to be woven into a womans belief system
from childhood. During pregnancy these beliefs and/
or fears can be reinforced by health care professionals
and the language of obstetrics which often reinforces
fears around vaginal birth (Fenwick et al 2006).
There is also some evidence that UK obstetricians are
more likely to comply with a maternal request for
CS compared to their European colleagues (Habiba
et al 2006). This potentially strengthens the view
to a society as a whole that CS is safe. This in turn
correlates to a general concern that in most Western
countries the discourse surrounding vaginal birth
focuses on risk and fear with a heavy reliance on

Olly, Fotolia.com

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Labour & Birth

technocratic birth (Davis-Floyd 2001). Womens

expectations of childbirth are being altered to accept
a process of medical intervention with less control
and less choice (Johanson et al 2002).
How society views birth and the differing cultural
attitudes towards vaginal birth are reflected to some
degree in the variation in reported rates of fear of
childbirth across continents (Fenwick et al 2009).
Geissbuehler & Eberhard (2002) reported a rate
as low as 5.3% in their Swiss study whereas other
studies have shown a fear of childbirth as high as
52% amongst US women (Lowe 2000) and 26% in
Australia (Fenwick et al 2009). This variation in rates
should be viewed with some caution as it could in
part be due to differing definitions of fear and severe
fear and by the sensitivity of the chosen measurement
scale. Rates of fear are also known to change over
time so depending on when women are asked will
influence a womans self-reported level of anxiety
and/or fear (Rouhe et al 2009, Hildingsson et al
2011).

The role of personality

Understanding the cultural context is important for
comprehending how women interpret and frame
the process of labour and birth and whether it is
viewed as fearful. When considering how women
make decisions and choices we must understand the
influence culture can have (Jomeen 2007). In terms
of further unravelling why women may be anxious
or fearful it is worth exploring demographics and
personality.
Primigravid women who fear childbirth have been
found to score higher for depression and generalised
anxiety (Laursen et al 2008, Strksen et al 2012),
reflecting findings from previous studies looking at
both primigravid and multiparous women (Saisto et al
2001, Zar et al 2001, Soderquist et al 2004) There is
also a link with perceived lack of social support, low
satisfaction with partners and low self-esteem being
seen as important predictors for severe fear (Saisto
et al 2001, Laursen et al 2008). This group is also at
risk of a negative birth experience (Waldenstrom et
al 2004). Social networks are important and women
tend to ask female relatives about their experiences;
a poor relationship with significant others especially
parents has been shown to predispose to a fear of
childbirth in primigravid women (Ryding et al 2007).
This also links to self-esteem and self-efficacy. Selfefficacy is an individuals belief that they can complete
a task and cope with the situation. In a sample
of 100 women suffering from an intense fear of
childbirth, more than 65% were worried about their
performance in labour and their bodies ability to give
birth (Sjogren & Thomassen 1997).
People with high self-efficacy beliefs visualise success,
while those with low self-efficacy beliefs visualise

MIDIRS Midwifery Digest 24:3 2014

failure and focus on things that can go wrong

(Bandura 1997). The most powerful source of selfefficacy is previous exposure and ability to cope in
the situation, which is relevant to multiparous women
but not first time mothers. Unsurprisingly, low levels
of self-efficacy are associated with high levels of
fear of childbirth (Lowe 2000, Salomonsson et al
2013). Self-efficacy is also linked to birth satisfaction;
Berentson-Shaw et als (2009) study of primigravid
women found that regardless of unplanned medical
intervention during birth, a strong sense of selfefficacy ensured a positive overall birth experience.
One other personality trait worthy of some discussion
is anxiety sensitivity, which has been found to
influence perception of pain in labour (Curzik &
Jokic-Begic 2011). Anxiety sensitivity relates to a
persons tendency to fear symptoms resulting from
being in an anxiety-inducing situation which can
be physical, psychological or social (Jokic-Berg et
al 2014). Spice et al (2009) found that high anxiety
sensitivity significantly predicted elevated levels
of fear even after controlling for parity and trait
anxiety. Jokic-Begic et al (2014) reduced this further
to an anxiety sensitivity in relation to the physical
dimension of labour, especially experiencing pain
as significant in predicting fear of childbirth. In
this study, levels of anxiety sensitivity relating to
psychological responses such as losing control, and
social aspects such as being embarrassed were not
predictive. When women have high levels of anxiety
sensitivity they are more likely to be hyper reactive
towards pain (Lang et al 2006), and bodily sensations
that they misinterpret as being dangerous leads to
avoidance behaviour, such as requesting a CS (Curzik
& Jokic-Begic 2011).

Supporting primigravid women

This complex picture can make it difficult to identify
women who are fearful and because of the complex
nature of the fears, a one size fits all approach to
diagnose and treat may be difficult. But identification
and support are important as fearing childbirth is
likely to raise maternal anxiety levels in pregnancy
which can have significant effects on birth outcomes
and the baby. This includes preterm labour and low
birth weight (Chung et al 2001), issues with maternalinfant attachment (Hart & McMahon 2006) and
an increased risk of adverse neuro-developmental
outcomes in the neonate (Van den Bergh et al 2005,
Talge et al 2007). A fear of childbirth is also linked
to an increased risk of emergency CS (Fenwick et al
2009), a more complicated labour and postpartum
depression (Saisto et al 1999, Melender 2002, Rouhe
et al 2009).
Most hospitals in the UK use the National Institute
for Health and Care Excellences (NICE) antenatal
care guidelines (2008) to screen for depression
in the antenatal period. Currently, there is no

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nationally adopted and agreed measure for assessing

psychological distress and/or fear of childbirth and,
before such a measure could be introduced, there
would need to be an appropriate pathway for referral.
King et al (2012) demonstrated that training midwives
in identifying and managing psychological issues can
significantly increase their confidence in managing
women with mild psychological distress. A metaanalysis of interventions aimed at reducing maternal
distress suggests that targeting women who are
more likely to develop, or are already suffering from
maternal distress could be useful, but it failed to find
an intervention with proven affect (Fontein-Kuipers et
al 2014).
Many studies have reported success with psychoeducative programmes for women with high levels
of anxiety and/or fear in pregnancy; these studies
tend to measure success in terms of numbers of
women choosing vaginal birth rather than CS (Saisto
et al 2001, Nerum et al 2006, Sydsjo et al 2012).
Rouhe et al (2013) looked specifically at primigravid
women randomised to group therapy and found
an increase in vaginal birth and greater satisfaction
with birth. Other studies have also observed that
antenatal counselling protects against a negative
birth experience for women with fears (Waldenstrom
et al 2006). Salmera-Aro et al (2012) measured
adaptation to motherhood in primigravid women and
found that a group intervention reduced their fear,
increased their preparedness for birth, and fostered
a positive adaptation to motherhood. Their method
incorporated the philosophy of self-efficacy and they
conclude that by enhancing a womans ability to feel
prepared for labour, including emotional readiness to
deal with setbacks, can have a long-term beneficial
effect on parenting and early mother-child bonding.
More recently, a feasibility study by Byrne et al (2014)
has shown that a mindfulness technique has the
potential to positively influence maternal self-efficacy
and reduce the fear of childbirth.
Given that most hospitals in the UK do not have
access to such support for women fearful of birth,
there are some other simple measures which have been
shown to be effective. Dialogue which concentrates
on coping mechanisms rather than assurances that
everything will be alright is important (Halvorsen et al
2010) as women need to feel confident that they can
deal with any eventuality. Fearful women are often
identified when they ask for a CS (Brodrick 2014). In
these cases it is important that the dialogue focuses on
exploring their fears, giving women time to talk rather
than just highlighting the risks involved in a CS which
adds little value (Nama & Wilcock 2011).
Many maternity units now have midwife-led clinics
where women can acknowledge and discuss fears
and plan ongoing support (Brodrick 2014, Butcher
2014); this is similar to other successful approaches
(Waldenstrom et al 2006). There is an assumption

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that fear of childbirth is increasing, however it is also

possible that women today feel more able to reveal
and discuss their fears than they used to (Laursen
et al 2008). Fear involves a loss of control, so
interventions should aim to help women take personal
responsibility for their own well-being as this has
been shown to increase birth satisfaction in first-time
mothers (Howarth et al 2011). Measures which help
promote resilience and psychological preparedness to
be able to deal with an unpredictable journey have the
potential to increase levels of self-efficacy and lead to
a better experience of birth (Salmela-Aro et al 2012).
Primigravid women also need support in making the
decision about mode of birth. If a woman with a fear
of vaginal childbirth makes an informed decision
to choose a CS then this should be respected (NICE
2011). Whilst maternal request for elective CS is an
emotive topic, it is important that for women with
a fear of childbirth psychological issues as well as
physical risks are discussed and considered. The most
important end-point is a well-adjusted mother and a
positive maternal-infant bond.

Conclusion
Women with a primary fear of childbirth can present
with a complex picture which IS unique to each
woman. If left untreated high levels of anxiety and
fear during pregnancy can negatively affect both
mother and baby. Understanding why primigravid
women are fearful and how best to support them is
a challenging but important part of antenatal care.
Health care professionals need to work together
to support these women to have a positive birth
experience.
Alison Brodrick, consultant midwife, Sheffield Teaching
Hospitals NHS Foundation Trust.

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Brodrick A. MIDIRS Midwifery Digest, vol 24, no 3,

September 2014, pp 327-332
Original article. MIDIRS 2014.

MIDIRS Midwifery Digest 24:3 2014