Psychological perspectives on fear of birth: heterogeneity, mechanisms and treatment Elisabet Rondung Main supervisor: Örjan Sundin Co-supervisor: Johanna Ekdahl Faculty of Human Sciences Thesis for Doctoral degree in Psychology Mid Sweden University Östersund, 2018-08-29 Akademisk avhandling som med tillstånd av Mittuniversitetet i Östersund framläggs till offentlig granskning för avläggande av filosofie doktorsexamen, fredag 26 oktober 2018, klockan 10.00, i sal F234, Mittuniversitetet Östersund. Seminariet kommer att hållas på svenska. Psychological perspectives on fear of birth: heterogeneity, mechanisms and treatment © Elisabet Rondung, 2018-08-29 Printed by Mid Sweden University, Sundsvall ISSN: 1652-893X ISBN: 978-91-88527-63-9 Cover photo: Elin Ternström Faculty of Human Sciences Mid Sweden University, 831 25 Östersund Phone: +46 (0)10 142 80 00 Mid Sweden University Doctoral Thesis 286 Table of contents Abstract ............................................................................................................. vii Summary in Swedish ........................................................................................ ix List of papers ..................................................................................................... xi Abbreviations ................................................................................................... xiii Definitions ........................................................................................................ xiv Preface ............................................................................................................... xv 1 Introduction ...................................................................................................... 1 Pregnancy and childbirth in the Swedish context ................................................. 1 Swedish antenatal care ................................................................................. 2 Giving birth in Sweden .................................................................................. 2 The Swedish model of care for fear of birth .................................................. 3 Fear of birth .......................................................................................................... 4 Fear of birth - a poorly defined concept ........................................................ 4 Assessing fear of birth .................................................................................. 5 Prevalence of fear of birth ............................................................................. 6 Common fears and worries relating to childbirth ........................................... 7 The role of parity in fear of birth .................................................................... 8 Risk- and protective factors for fear of birth .................................................. 9 Fear of birth and emotional disorders ......................................................... 11 Psychological factors relating to fear of birth .............................................. 12 Consequences of fear of birth ..................................................................... 13 Treating fear of birth .................................................................................... 15 Psychological perspectives on fear and anxiety ................................................. 17 Emotion ....................................................................................................... 17 Fear and anxiety – similar yet distinctive emotional states ......................... 17 Clinical manifestations of fear, anxiety, and worry ...................................... 19 Etiology of clinical anxiety: the interaction of vulnerabilities and stress ...... 20 Fear and anxiety as learned responses: pathways of acquisition ............... 21 A transdiagnostic perspective on fear and anxiety ..................................... 22 Treating fear and anxiety using Cognitive Behavior Therapy ..................... 22 Summary and rationale ...................................................................................... 24 2 Aim .................................................................................................................. 25 3 Methods .......................................................................................................... 26 Study 1 ............................................................................................................... 27 Interdisciplinary research setting ................................................................ 27 Study design and setting ............................................................................. 27 Participants and procedures ....................................................................... 28 Measurements ............................................................................................ 29 Guided ICBT ............................................................................................... 31 Standard care ............................................................................................. 33 Data analysis .............................................................................................. 33 Study 2 ............................................................................................................... 34 Design and setting ...................................................................................... 34 Participants and procedures ....................................................................... 34 Data analysis .............................................................................................. 36 Study 3 ............................................................................................................... 36 Design and setting ...................................................................................... 36 Participants and procedures ....................................................................... 36 Measurements ............................................................................................ 36 Data analysis .............................................................................................. 38 Study 4 ............................................................................................................... 38 Design and setting ...................................................................................... 38 Participants and procedures ....................................................................... 38 Measurements ............................................................................................ 39 Data analysis .............................................................................................. 40 4 Ethical considerations .................................................................................. 41 5 Summary of findings ..................................................................................... 42 Study 1 ............................................................................................................... 42 Study 2 ............................................................................................................... 44 Study 3 ............................................................................................................... 45 Study 4 ............................................................................................................... 47 6 Discussion ..................................................................................................... 49 Fear of birth or birth-related anxiety? ................................................................. 49 Is fear of birth a specific and coherent concept? ................................................ 50 What about primary and secondary fear of birth? .............................................. 52 Are women fearing birth a heterogeneous group? ............................................. 54 A transdiagnostic perspective on fear of birth? .................................................. 55 Is (Internet-delivered) CBT effective in treating fear of birth? ............................. 57 7 Methodological considerations .................................................................... 60 Measurement issues .......................................................................................... 60 Representativeness of the samples ................................................................... 61 Treatment conditions .......................................................................................... 62 Treatment adherence ......................................................................................... 63 Outcomes ........................................................................................................... 65 Statistical issues ................................................................................................. 67 Methodological issues in literature reviews ........................................................ 68 8 Conclusions and clinical implications ........................................................ 70 9 Future directions ........................................................................................... 73 Acknowledgements .......................................................................................... 74 References .......................................................................................................