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Care for Fear of Childbirth - an Evaluation of
Birth Preparation by Midwives
Elsa Lena Ryding, MD, PhD, Cecilia Onell, RN, RM,
Åsa Persson, RN, RM, Linda Kvist, RN, RM,
BScN Department of Obstetrics and Gynecology,
Helsingborg Hospital Ltd, Sweden
Background
Childbirth experience The degree of frightening
experience of birth (W-DEQ score) in 53 women
treated for fear of childbirth during pregnancy
(Klara women) and their controls__________________
___________ Klara women 44.320.5 Controls
29.717.4 Mean difference 14.56 95 CI
19.7-9.4 Mean W-DEQ score and range after
different modes of delivery Klara
women Control women Emergency cesarean (n6)
47.7 (17.2-100) 40.0 (19-66) Elective
cesarean (n8) 39.5 (8-54.2) 32.0 (
5-68) Vaginal delivery (n39) 44.7
(15-94) 27.5 ( 0-72) including instrumental
vaginal 62.8 (40-94) 26 and 72 (5
Klara women and 2 controls) Primiparous women
had a tendency towards more negative delivery
experience Posttraumatic stress Degree of
posttraumatic stress reactions (IES score) in 53
women treated for fear of childbirth (Klara
women) and their controls_________________________
___________________ Median IES score and
range Klara women 11.5 (0-60) Controls
9.0 (0-42) p0.058 Women with IESgt30 (19
of the Klara women and 2 of the controls) may
have posttraumatic stress disorder (PTSD) after
recent childbirth. Satisfaction with care A
majority of the women were satisfied with the
antenatal preparations for birth and with the
care during and after delivery. Expectations
(both groups) to be listened to and to be
taken seriously. Expectations were fulfilled for
the majority of women in both groups, since only
three in each group were disappointed with the
care. It was over my expectations. I got some
different ideas Advice The women in both
groups advised us professionals to listen, to be
sensitive and affirmative. Several Klara women
emphasised that plans and doctors orders should
be respected by the staff on duty during their
delivery. Wishes The Klara women had hardly any
suggestions for better antenatal care. Instead
they took the opportunity to say thank you. You
took care of me in an unbelievable way and I will
remember it all my life. Also the control women
appeared pleased with the care given. The most
prevalent wish from both groups Spend more time
with the patient!
Long and difficult rehabilitation
incontinence
In all 1981 women returned the self-assessment
scale Wijma Delivery Expectancy Questionnaire
(W-DEQ A) at 32 weeks of pregnancy. The stronger
the fear of childbirth, the greater was the risk
of a subsequent emergency cesarean section.
Ref Ryding EL, Wijma B, Wijma K, Rydhström
H.Fear of childbirth during pregnancy may
increase the risk of emergency cesarean section.
Acta Obstet Gynecol Scand 1998,77542-547



exhausted
The stronger the fear of childbirth, the greater
was also the risk of a deteriorated
psychological well-being postpartum. Care for
fear of childbirth is provided by various
professionals. In Sweden, consultations by
specially trained midwives is a common procedure.
forceps
Unbearable pain
danger of operation
Klara - care for women with fear of childbirth
ventouse
long time
The Klara group consists of 8 midwives working on
the delivery ward, and one doctor with a double
roll of supervisor and team obstetrician. The
midwives encourage the women to talk about the
nature of their fear, and about previous
traumatic childbirth experiences. When the woman
has gained enough confidence to be able to
visualise the impending delivery in a more
positive manner, individual birth plans are made
by the woman/couple, or by the midwife, or by the
doctor according to the needs of the woman and
the obstetric situation. Rarely, cesarean
section is recommended for psychological reasons.
More often, women who want a cesarean are given a
choice after a trial of preparation of vaginal
birth. In selected cases the woman is offered a
planned vaginal delivery (induction of labour
at about term) as an alternative to the cesarean.
Drawing by a pregnant woman with fear of
childbirth

• The aim of the study
• The aim of this clinical evaluation was to answer
  the following questions
• Is the delivery experience of the women who
  consulted the Klara group as good as, or more
  frightening, than the experience of average
  women?
• Do women treated by the Klara group report
  symptoms of posttraumatic stress reactions after
  childbirth at a higher rate than the average
  woman or is the rate the same for all?
• Were the women who applied for help for fear of
  childbirth satisfied with the care provided by
  the Klara group?

Conclusions The cesarean section rate was high
in the group of women treated for fear of
childbirth - the Klara women. In spite of
their overall satisfaction with the care given,
the women who had applied for help for fear of
childbirth reported a more negative delivery
experience and more often symptoms of a strong
posttraumatic stress reaction than did the
controls. Pregnant women who have applied for
help for fear of childbirth are a vulnerable
group. Our Klara women did not appear to be cured
of their fear, but their deliveries may have been
better than expected. The fear did not totally
disappear, but I felt less panic. In order to
better evaluate the care given, we need to
compare women with fear of childbirth who elect
to attend the program with those who refuse care.
Mode of delivery of the 66 Klara women
Cesarean section 18 (27) Total for the
department 10 emergency 8 (5
obstetric, 3 psychosocial indication) elective
10 (2 obstetric, 8 psychosocial
indication) Instrumental vaginal delivery
5 (8) Total for the department 7
Case histories Three women with fear of
childbirth were not satisfied with the care
provided. The histories of these women are
presented below, including some facts from the
hospital records. Alterations have been made in
order to ensure confidentiality.
Case history III They should not to try to
persuade anyone to have a vaginal
delivery. Cindy was a nulliparous woman in her
thirties. She had suffered for many years from a
disorder of breathing. Extensive investigations
had revealed no asthma or anatomical defects.
Cindy feared physical and mental strain, but had
managed to lead a normal social life, although
somewhat restricted. She was absolutely convinced
that she had to have a cesarean for health
reasons. Her obstetricians referred her to a
Klara midwife with the hope the she would change
her decision. Cindy was not motivated. In the end
her doctor agreed to perform a cesarean. Cindy
had a good birth experience. (W-DEQ score 8, IES
score 8).
Case history II The doctor on duty did not care
a bit about my contract. So, I terrible delivery
number two Betty had given birth in -97 by
emergency cesarean section after 6 hours of
second stage ineffective labour. After birth she
developed a panic disorder with agoraphobia.
During the present pregnancy she felt much better
and wanted a vaginal delivery with guarantee
that a cesarean would be performed earlier if she
needed. A plan was made accordingly. Betty went
into spontaneous labour at term and was soon
fully dilated. Three hours later the foetus had
failed to descend the birth channel, and Betty
began to panic. The obstetrician on duty asked
her to try another hour of second stage labour
before he finally decided on a cesarean section.
(W-DEQ score 100, IES score 60)
Case history I I dont think that I got any help
with my problems at all. they should not
treat young mothers and fathers like shit but
show respect, this concerns all doctors because
we have feelings too. Annie was a 20 year old
woman with a history of a traumatic legal
abortion and of mistrust in health care
providers. She experienced vaginal birth after 34
weeks of pregnancy. Her infant was admitted to
the neonatal unit. (W-DEQ score 59, IES score 60)
Methods The questionnaire consisted of two
self-rating scales and four open questions about
satisfaction with preparations for birth and
suggestions for better care. The inquiry was
conducted by a person who is not a member of the
Klara group. The Wijma Delivery
Expectancy/Experience Questionnaire (W-DEQ)
measures the degree of fear of
childbirth/frightening experience of delivery.
The version W-DEQ B 20 is used after childbirth,
vaginal or cesarean. The scale has 20 items with
a scoring range of 0-5 for each item. The
significance of difference in W-DEQ score between
the two groups was tested by Students t-test.
The Impact of Event Scale (IES) records the
presence and frequency of post-traumatic stress
symptoms after any trauma, in this study in
relation to childbirth. The scale has 15 items
with a scoring range of 0-5 for each item. The
significance of difference in IES score between
the two groups was tested by the Mann Whitney
U-test.
Subjects During 1999 a total of 66 women (3,4 of
the 1948 women who gave birth at the
department) consulted the midwives of the Klara
group. 62 were eligible for the study. The rate
of nulliparous women was 30 among the Klara
women compared to 43 in the whole population.
A questionnaire was returned by 53 (85) of the
women treated by the Klara group at 1-13 months
postpartum. Controls were matched for parity and
mode of delivery. Two controls were chosen from
the delivery ward register for each of the
treated women, as close to the same delivery date
as possible. 97 (78) of the controls returned
the questionnaire. The first control was chosen
for comparison. The mean age of the women of both
groups was about 30 years.
The following open questions were asked 1. What
did you expect from the Klara midwife/ from the
childbirth preparation at the antenatal
clinic? 2. Were your expectations fulfilled? 3.
If you could give us professionals some advice,
what would you like to say? What is important for
us to remember? 4. I would have wished that the
following had been different The womens
answers were analysed for themes and
patterns. The study was approved by the
research ethics committee at the University of
Lund. It was financially supported by Stig and
Ragna Gorthons Foundation.