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Identification and Treatment of Women with a Fear of Birth

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Identification and Treatment of Women with a Fear of Birth Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1459 Identification and Treatment of Women with a Fear of Birth ELIN TERNSTRÖM ACTA UNIVERSITATIS UPSALIENSIS ISSN 1651-6206 ISBN 978-91-513-0320-8 UPPSALA urn:nbn:se:uu:diva-347569 2018 Dissertation presented at Uppsala University to be publicly examined in Sal IX, Universitetshuset, Biskopsgatan 3, Uppsala, Wednesday, 30 May 2018 at 13:00 for the degree of Doctor of Philosophy. The examination will be conducted in Swedish. Faculty examiner: Professor Mirjam Lukasse (Department of Nursing and Health Promotion, Oslo and Akershus University College of Applied Sciences). Abstract Ternström, E. 2018. Identification and Treatment of Women with a Fear of Birth. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1459. 84 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-513-0320-8. Although a fear of birth affects many women during pregnancy and is associated with adverse birth outcomes, it is rarely measured in clinical practice and evidence-based treatments are lacking. The aim of this thesis was to assess the clinical utility of the Fear of Birth Scale, and to evaluate the effect of guided Internet-based cognitive behavior therapy compared with standard care on the levels of fear of birth in pregnant and postpartum women. This thesis consists of four papers originating from three studies. The Fear of Birth Scale was used to measure fear of birth among pregnant women in all three studies. In Study I, prevalence of fear of birth among Swedish-born and foreign-born pregnant women was measured, and in Study II, 31 pregnant women were interviewed about their thoughts when assessing fear of birth. In Study III, a multicenter randomized controlled trial was conducted to compare guided Internet-based cognitive behavior therapy (ICBT) with standard care for pregnant women with a fear of birth. Fear of birth was identified among 22% of the pregnant women. Prevalence was twice as high among the foreign-born women (37%) compared to the Swedish-born women (18%). When asking the participants what they thought when assessing their fear on the Fear of Birth Scale, they confirmed that they had understood the measurement intent of the scale. The randomized controlled trial showed that fear of birth decreased during pregnancy and postpartum in both groups. However, the levels of fear decreased more in the guided ICBT-group when measuring fear of birth up to one year postpartum. The changes in fear of birth over time did not differ between parity groups. Altogether, these results suggest that the Fear of Birth Scale is a suitable screening instrument for identifying pregnant women with a fear of birth in a clinical setting and that such screening would be beneficial, as it probably would increase the chance of achieving a more equitable care. As the effect of time during pregnancy and postpartum was most evident in reducing fear of birth, this can be communicated to pregnant women, along with a continuous dialogue about how the women experience fear during pregnancy. Keywords: Fear of birth, Fear of Birth Scale, foreign-born, guided Internet-based cognitive behavior therapy, midwifery, pregnancy, randomized controlled trial, screening, treatment Elin Ternström, Department of Women's and Children's Health, Akademiska sjukhuset, Uppsala University, SE-75185 Uppsala, Sweden. © Elin Ternström 2018 ISSN 1651-6206 ISBN 978-91-513-0320-8 urn:nbn:se:uu:diva-347569 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-347569) To all women who have given birth, those who want to give birth, and to those who do not List of Papers This thesis is based on the following papers, which are referred to in the text by their Roman numerals. I Ternström, E., Hildingsson, I., Haines, H. & Rubertsson, C. (2015) Higher prevalence of childbirth related fear in foreign- born pregnant women – Findings from a community sample in Sweden. Midwifery; 31:445–50. II Ternström, E., Hildingsson, I., Haines, H. & Rubertsson, C. (2016) Pregnant women’s thoughts when assessing childbirth related fear on the Fear of Birth Scale. Women and birth; 29:e44–9. III Ternström, E., Hildingsson, I., Haines, H., Karlström, A., Sundin, Ö., Ekdahl, J., Segeblad, B., Larsson, B., Rondung, E. & Rubertsson, C. (2017) A randomized controlled study com- paring Internet-based cognitive behavioral therapy and coun- selling by standard care for fear of birth – A study protocol. Sexual & Reproductive Healthcare; 13 (Supplement C):75–82. IV Rondung, E., Ternström, E., Hildingsson, I., Haines, H., Sundin, Ö., Ekdahl, J., Karlström, A., Larsson, B., Segeblad, B., Baylis, R. & Rubertsson, C. A randomized controlled trial comparing Internet-based cognitive behavior therapy with standard care for women with fear of birth. (Submitted) Reprints were made with permission from the respective publishers. Cover: Bea, Finn and Otto, by Sara Landstedt, Day Fotografi. Contents Introduction ................................................................................................... 11 Background ................................................................................................... 13 Defining fear of birth ................................................................................ 13 Prevalence of fear of birth ........................................................................ 14 Measuring fear of birth ............................................................................. 14 Wijma Delivery Expectancy Questionnaire ........................................ 15 Other Likert-type scales ....................................................................... 16 The Fear of Birth Scale ........................................................................ 16 Objects of fear of birth ............................................................................. 17 Background factors relating to fear of birth ............................................. 18 Characteristics of women with a fear of birth ...................................... 18 Foreign-born women in Sweden .......................................................... 18 Mental health and fear of birth ............................................................ 20 Consequences of fear of birth ................................................................... 21 Birth outcomes ..................................................................................... 21 Birth experiences ................................................................................. 22 Treating fear of birth ................................................................................ 23 Internet-based cognitive behavior therapy ........................................... 24 Theoretical framework ............................................................................. 25 Rationale ....................................................................................................... 27 Aims .............................................................................................................. 28 Methods ........................................................................................................ 29 Overview of the included studies ............................................................. 29 Study I (Paper I) ....................................................................................... 30 Design .................................................................................................. 30 Recruitment and participants ............................................................... 30 Data collection ..................................................................................... 30 Analysis ............................................................................................... 31 Study II (Paper II) .................................................................................... 32 Design .................................................................................................. 32 Recruitment and participants ............................................................... 32 Data collection ..................................................................................... 32 Analysis ............................................................................................... 33 Study III (Papers III and IV) .................................................................... 35 Design .................................................................................................. 35 Recruitment and participants ............................................................... 35 Intervention – guided Internet-based cognitive behavior therapy ....... 38 Standard care for fear of birth – midwife-led counseling .................... 39 Data collection ..................................................................................... 40 Analysis ............................................................................................... 40 Ethical considerations .............................................................................. 42 Summary of findings ..................................................................................... 44 Prevalence of fear of birth (Study I) ......................................................... 44 Women’s thoughts when assessing fear of birth (Study II) ..................... 45 Worry – unspecific feelings, sensations, and thoughts about an unpredictable event .............................................................................
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