Obstetric outcome after intervention for severe ... - Wiley Online Library

General obstetrics

DOI: 10.1111/1471-0528.12011 www.bjog.org

Obstetric outcome after intervention for severe fear of childbirth in nulliparous women – randomised trial H Rouhe,a K Salmela-Aro,b R Toivanen,a M Tokola,a E Halmesma¨ki,a T Saistoa a Helsinki University Central Hospital, Department of Obstetrics and Gynaecology, Helsinki, Finland b University of Helsinki, Helsinki, Finland Correspondence: Dr H Rouhe, Department of Obstetrics and Gynaecology, Helsinki University Central Hospital, PO Box 800, 00029 HUS, Finland. Email [email protected]

Accepted 23 August 2012. Published Online 2 November 2012.

Objective To compare the numbers of vaginal deliveries and

delivery satisfaction among women with fear of childbirth randomised to either psychoeducation or conventional surveillance during pregnancy. Design Randomised controlled trial. Setting Maternity unit of Helsinki University Central Hospital. Population Fear of childbirth was screened during early pregnancy by the Wijma Delivery Expectancy Questionnaire (W-DEQ-A). Of 4575 screened nulliparous women, 371 (8.1%) scored ‡100, showing severe fear of childbirth. Methods Women with W-DEQ-A ‡100 were randomised to

intervention (n = 131) (psychoeducative group therapy, six sessions during pregnancy and one after childbirth) or control (n = 240) (care by community nurses and referral if necessary) groups. Obstetric data were collected from patient records and delivery satisfaction was examined by questionnaire.

Results Women randomised to the intervention group more often had spontaneous vaginal delivery (SVD) than did controls (63.4% versus 47.5%, P = 0.005) and fewer caesarean sections (CSs) (22.9% versus 32.5%, P = 0.05). SVD was more frequent and CSs were less frequent among those who actually participated in intervention (n = 90) compared with controls who had been referred to consultation (n = 106) (SVD: 65.6% versus 47.2%, P = 0.014; CS: 23.3% versus 38.7%, P = 0.031). Women in intervention more often had a very positive delivery experience (36.1% versus 22.8%, P = 0.04, n = 219). Conclusions To decrease the number of CSs, appropriate

treatment for fear of childbirth is important. This study shows positive effects of psychoeducative group therapy in nulliparous women with severe fear of childbirth in terms of fewer CSs and more satisfactory delivery experiences relative to control women with a similar severe fear of childbirth. Keywords Delivery mode, delivery satisfaction, fear of childbirth.

Main outcome measures Delivery mode and satisfaction. Please cite this paper as: Rouhe H, Salmela-Aro K, Toivanen R, Tokola M, Halmesma¨ki E, Saisto T. Obstetric outcome after intervention for severe fear of childbirth in nulliparous women – randomised trial. BJOG 2013;120:75–84.

Introduction It has been estimated that 6–10% of all pregnant women suffer from severe fear of childbirth.1–5 Severe fear of childbirth is as common in nulliparous as in parous women.3,4,6 This fear of childbirth may overshadow the whole pregnancy, complicate labour and lead to difficulties in the mother–infant relationship and to postpartum depression.7–9 Fear of childbirth is very often behind maternal requests for caesarean sections (CSs) and therefore, if untreated, will lead to operations without medical indication.2,10–12 CS is a major abdominal operation with

serious risks for the mother and child.13–15 In recent decades, fear of childbirth has been related to a major increase in CS rates, mainly elective CS, but also emergency CS.2,9,11,16 Previous studies have shown the confounding effects of fear of childbirth and mental health problems during pregnancy on pregnancy outcomes. Some studies have shown that both anxiety and depression during pregnancy are associated with an increased risk of preterm delivery, low birthweight and other obstetric complications,17–19 whereas others have not shown a connection with neonatal outcome.20,21

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Obstetricians worldwide are aware of the significant increase in the numbers of CSs in most countries. However, there is no settled clinical practice on how to treat women with severe fear of childbirth and request for CS. In the Nordic countries, women with fear of childbirth have been treated in various ways to relieve the fear and, if possible, to avoid CS.11,22–25 Women with fear of childbirth have been treated by trained midwives, obstetricians and psychologists, offering different kinds of therapy and support.11,22–25 The results have been positive, with 50–85% of women with fear of childbirth preparing themselves for vaginal delivery and avoiding CS.11,22–25 Group psychoeducation and crisis-oriented support have been shown to be most effective in avoiding CS,22,23 but previous studies have not been randomised. In obstetrics, the effect of the treatment for fear of childbirth is mostly evaluated by the numbers of CSs. However, it is also important to show better adjustment to the pregnancy and parenthood. Recently, it has been shown that it is possible to increase a mother’s preparedness for childbirth, which, in turn, predicts an increase in positive motherhood and parenting.26 With the aid of a cognitive behavioural approach, women were able to deal more effectively with possible setbacks and to increase their related coping skills. The aim of this randomised clinical trial was to compare the effect of group intervention on the mode of delivery among women with severe fear of childbirth with the clinical course of pregnancy and delivery. Nulliparous women were first screened at the beginning of pregnancy, and the most fearful were then randomised to either group therapy intervention or the control group for conventional care.

Materials and methods The goal of this study was to examine the effect of psychoeducative group therapy for primary fear of childbirth in a randomised setting. Between October 2007 and August 2009, 12 000 questionnaires were available to consecutive and unselected Finnish- and Swedish-speaking pregnant women who participated in routine ultrasound screening at the gestational age of 11–13 weeks in the maternity clinics at the Department of Obstetrics and Gynaecology, University of Helsinki (HUCH). Figure 1 shows the screening and randomisation protocol. Fear of childbirth was screened with the Wijma Delivery Expectancy Questionnaire (W-DEQ-A) (see later27). All participants gave their informed consent. Nulliparous women whose W-DEQ-A score was above the 95th percentile (W-DEQ-A sum score ‡100) were included in our study. The final study population consisted of 371 women who were randomised (by one of the main researchers, TS) to the intervention or control group in the proportion of 1:2 in balanced blocks of 18 by sealed opaque envelopes.

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Finally, there were 131 women in the intervention group and 240 women in the control group. Women in the intervention group were contacted and offered group therapy for fear of childbirth. The only exclusion criteria were manifest psychosis and severe depression. Those randomised to the control group received a letter in which they were recommended to discuss their fear of childbirth in their primary healthcare maternity unit. The W-DEQ-A is a standardised screening method for fear of childbirth.27 W-DEQ-A is a self-assessment scale; it includes 33 statements about childbirth, with a scale ranging from ‘not at all’ (zero) to ‘extremely’ (five), and a maximum score of 165 and a minimum score of zero. The higher the score, the more severe the fear of childbirth. A W-DEQ-A sum score of ‡100 has been used in previous studies4,9,28 to represent phobic fear of childbirth. The Wijma Delivery Experience Questionnaire (W-DEQ-B) is a postpartum version of W-DEQ-A, and examines the delivery experience with a similar scale and maximum and minimum scores and cut-off points. After approval from the copyright holder (K. Wijma, Division of Obstetrics and Gynaecology, Department of Health and Environment, Faculty of Health Sciences, Linko¨ping University, Linko¨ping, Sweden, pers. comm.), W-DEQ-A and W-DEQ-B were translated from Swedish into Finnish and validated for the Finnish population.3 For Swedish-speaking women, the W-DEQ questionnaires were available in original Swedish form. In this study, the Chronbach alpha reliability coefficient was 0.937 for W-DEQ-A and 0.947 for W-DEQ-B, which both showed good reliability. After filling in W-DEQ-A, women were asked to mark an ‘X’ on a visual analogue scale (VAS) on how afraid they were of childbirth (scale from zero to ten). Previous miscarriages or termination of pregnancy (TOP) were recorded. After screening and randomisation, the patients and their partners in both groups separately received three questionnaires to consent and complete: (1) in the middle of pregnancy; (2) at the end of the third trimester; and (3) 3 months after delivery. These questionnaires included psychological, social and pregnancy- or delivery-related questions. The postnatal questionnaire contained both W-DEQB and an eight-item scale about delivery satisfaction (delivery satisfaction scale, DSS; see Table 1).29 The higher the DSS score, the more positive the childbirth experience. If the questionnaires were not returned, the women were reminded twice by email, or, in cases without email, they were sent a new questionnaire by mail. Data on the deliveries were derived from the hospital obstetric patient records. The variables collected were as follows: antenatal care concerning fear of childbirth, delivery mode, duration of labour and delivery (phases 1 and 2), postpartum haemorrhage (ml), usage of epidural or spinal analgesia, birthweight and umbilical arterial pH of the new-

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Treatment of women with fear of childbirth

Figure 1. Flow chart to describe the screening and randomisation model of the study.

Table 1. Delivery satisfaction questions. DSS is the sum score of these answers29.

1. 2. 3. 4. 5. 6. 7. 8.

Was your delivery a positive experience? Did you receive sufficient support from the obstetric ward personnel? Did you receive sufficient support from your partner? Was your labour painful? Did you get enough pain relief during labour? Did you feel safe during the labour? Did you have enough influence on the treatment you received during labour? Did the obstetric ward personnel patronize you too much during the labour?

born, Apgar scores, and interventions during the third stage of labour (suturing or surgical evacuation of placenta or membranes postpartum). The primary outcome was the number of uneventful spontaneous vaginal deliveries.

Very much

Much

Some

Only little

Not at all

5 5 5 1 5 5 5 1

4 4 4 2 4 4 4 2

3 3 3 3 3 3 3 3

2 2 2 4 2 2 2 4

1 1 1 5 1 1 1 5

In our study, the intervention method of treating these women with severe fear of childbirth was psychoeducative group therapy led by four different psychologists with special group therapeutic skills in pregnancy-related issues.

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Each group consisted of a maximum of six nulliparous women. Each group was led by the same psychologist from the beginning to the end. The starting point of group therapy was planned to be at approximately the 26th week of pregnancy. Six group sessions were held during pregnancy and one session with the newborns 6–8 weeks after delivery. Each 2-hour session had a certain structure: a focused topic and a 30-minute guided relaxation exercise using a compact audio disk developed for this purpose. This relaxation exercise guided the participants through stages of imaginary delivery in a relaxed state of mind with positive, calming and supportive suggestions. Each participant was encouraged to associate birth giving with images related to opening (e.g. the opening of a flower bud). The outline of our psychotherapeutic intervention is presented in Table 2. The meeting focusing on pain relief took place in a delivery room with a midwife specialised in treating fear of childbirth. Partners participated in one of the group sessions. In our study protocol, women in the intervention group had no planned visits with an obstetrician. This study was approved by the Ethics Committee for Gynaecology and Obstetrics, Otology, Ophthalmology, Neurology and Neurosurgery of the Helsinki University Central Hospital (376/E9/05 from 27 October 2005), and informed consent was collected from all participants who filled in any of the questionnaires. Analyses were carried out in two ways (see Figure 1). First, we compared the original randomised groups using the intention-to-treat principle. Second, we compared those women who actually participated in group therapy (n = 90) with controls who sought and received some special support or care for fear of childbirth during pregnancy (see later) (n = 106).

Statistical analyses were carried out using spss 17.0 (Statistical Package for the Social Science for Windows, Chicago, IL, USA). The chi-squared test was used to measure the differences between groups in classified variables, and the t-test was used for parametric variables. P £ 0.05 was considered to be significant. The power calculations showed that 135 women in the intervention group and 135 controls were needed to detect a difference of 30% between the group therapy and the controls in the frequency of successful vaginal delivery (80% in the group therapy and 50% in the controls11,23) with 80% power at P = 0.05. After power analysis and consultation with a statistician, we decided to recruit two control women for each case, as we also wanted to optimise the number of returned questionnaires from the participants in the control group who would not receive any active action on behalf of the investigators. We also calculated how many women needed to be treated by group therapy (number needed to treat, NNT) to avoid one CS when the control group served as a reference.

Results The background characteristics of the study population are shown in Table 3. There were no significant differences between the groups in any of the studied background variables, for example age, social status, education, previous pregnancies or marital status. The participation of those invited to group therapy was 69% (n = 90). The reasons for not attending group therapy are shown in Figure 1. The women who attended group therapy were not more significantly fearful than women who did not attend (W-DEQ-A sum score 114 versus 112, P = not significant). Seventy-six of 240 control women

Table 2. Outline of the psychotherapeutic intervention Group session 1 2 3 4 5 6 7

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Focused topic (duration, 90 minute)

Relaxation

In attendance

Information about fear and anxiety, group therapy and effects of relaxation Information about fear of childbirth, normalisation of individual reactions and information about stages of labour Hospital routines, birth process and pain relief Becoming a family, changes in relationship, parenthood and enhancing mutual understanding between becoming parents Becoming a mother, recognising the signs of postnatal depression and bonding with the fetus Completing preparation for delivery and birth plan Meeting 2–3 months after delivery with newborns, discussion of delivery experiences, detection of trauma and depression symptoms, discussion of mother–infant relationship

Guided 30 minute

Therapist

Guided 30 minute

Therapist

Guided 30 minute Guided 30 minute

Therapist, midwife Therapist, partner

Guided 30 minute

Therapist

Guided 30 minute Guided 30 minute

Therapist Therapist

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Treatment of women with fear of childbirth

Table 3. Background characteristics of the study population (difference between groups was tested by t-test for parametric variables and chisquared test for categorical variables) Variable

Age (years), mean ± SD Occupation, n (%)* Upper white-collar workers Lower white-collar workers Employees Students University education, n (%)* Co-habiting, n (%)* Previous miscarriages, n (%) Previous termination of pregnancy, n (%) Gestational age at screening point (weeks), mean ± SD W-DEQ-A score, mean ± SD VAS, mean ± SD VAS > 5, n (%) Gestational age at beginning of intervention (weeks) Delivery satisfaction questionnaire returned, n (%)

Intervention group (n = 131)

Control group (n = 240)

P

29.3 ± 4.6

29.4 ± 4.8

0.90

41 (38.3) 33 (30.8) 22 (20.6) 10 (7.6) 43 (40.6) 104 (97.2) 15 (11.5) 21 (16.0)

65 (37.1) 46 (26.3) 52 (29.7) 10 (4.2) 69 (40.1) 161 (91.0) 40 (16.7) 41 (17.1)

0.90 0.42 0.10 0.34 0.68 0.61 0.22 0.89

13.7 ± 3.8

13.5 ± 3.8

0.58

113 ± 11 7.8 ± 1.6 124 (94.7) 27.6 ± 3.9

113 ± 12 7.7 ± 1.6 226 (94.2) NA

0.56 0.45 1.00

83 (63.5)

136 (56.7)

0.28

NA, not applicable to this group; SD, standard deviation; VAS, visual analogue scale; W-DEQ-A, Wijma Delivery Expectancy Questionnaire. *Data missing n = 25/68.

were sent to an outpatient maternity clinic for special consultation because of fear of childbirth; they met with an obstetrician one to five times and/or a midwife one to four times. Further, 30 control women sought and participated in a special childbirth preparation class led by a specially trained midwife in our maternity hospital two to six times during pregnancy. Thus, of the 240 women randomised to the control group, 106 received specialised care for fear of childbirth, with the remaining 134 cared for by community health nurses and GPs only. The control women who searched for specialised care for fear of childbirth were more fearful than control women who did not search for specialised care (W-DEQ-A mean sum score 115 versus 111, P = 0.014). Table 4 provides a summary of the obstetric data of the intervention and control groups using the intentionto-treat model. The total CS rate was 29.1% [the average CS rate was 16.3% in Finland in 2010 (www.stakes.fi/EN/ tilastot/statisticsbytopic/reproduction/index.htm)]. Figure 2 demonstrates the statistically significant difference between the groups with regard to spontaneous vaginal deliveries [83 (63.4%) versus 114 (47.5%), P = 0.005]. There was also a significant difference in CS rates [30 (22.9%) versus 78 (32.5%), P = 0.05]. Emergency CS was conducted more often in the control group [16 (12.2%) versus 47 (19.6%),

P = 0.05]. The indication for emergency CS was most often imminent asphyxia or prolonged delivery. Table 5 shows the obstetric results of women who participated in group therapy alongside those of the controls who received specialised care. Women who attended group therapy had spontaneous vaginal birth significantly more often than did specially treated control women [59 (65.6%) versus 50 (47.2%), P = 0.014]. There was also a significant difference in CS rates [21 (23.3%) versus 41 (38.7%), P = 0.031]. CS by maternal request (fear of childbirth) was performed for 11 women having group therapy (12.2%) versus 24 women in the control group (22.6%) (P = 0.064). NNT to avoid one CS for any indication was 6.5 in favour of group therapy, which means that, by treating seven severely fearful women by group therapy, we can avoid one CS compared with conventional care. There was no difference between the groups in terms of neonatal outcome (see Tables 4 and 5). The DSS questionnaires were returned by 83 (63.5%) women in the intervention group and by 136 (56.7%) control women (P = not significant). The DSS mean scores in Table 4 show that there was no statistically significant difference between the groups. When looking at the most positive delivery experiences, we found that more women in the intervention group had a very positive experience

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Table 4. Obstetric and delivery satisfaction information, intention-to-treat model, comparison between the groups (difference between groups was tested by t-test for parametric variables and chi-squared test for categorical variables) Variable

Intervention group (n = 131)

Control group (n = 240)

P

83 (63.4) 18 (13.7) 30 (22.9) 14 (10.1) 16 (12.2) 85 (84.2) 30 (22.9) 534 ± 484 10.1 ± 5.8 644 ± 378 36 ± 33 39.7 ± 1.5

114 (47.5) 48 (20.0) 78 (32.5) 31 (12.9) 47 (19.6) 138 (85.2) 50 (20.8%) 589 ± 538 10.8 ± 5.7 676 ± 341 32 ± 22 39.6 ± 1.6

0.005 0.16 0.05 0.62 0.05 >0.99 0.692 0.35 0.37 0.50 0.32 >0.99

3532 ± 550 8 (6.1) 14 (10.7) 15 (14.9) 30.1 ± 6.1

3486 ± 518 16 (6.7) 25 (10.4) 16 (9.9) 28.4 ± 6.5

0.44 >0.99 >0.99 0.24 0.06

30 (36.1)

31 (22.8)

0.04

63.0 ± 32

73.7 ± 29

0.02

Spontaneous vaginal delivery, n (%) VE, n (%) CS, n (%) Elective CS, n (%) Emergency CS, n (%) Epidural or spinal analgesia, n (%)* Induction of labour, n (%) Bleeding (ml), mean ± SD Stage I (hours), mean ± SD* Stage I (minutes), mean ± SD* Stage II (minutes), mean ± SD* Gestational age at delivery (weeks), mean ± SD Birthweight (g), mean ± SD pH < 7.10, n (%) Apgar (1 minute) < 7, n (%) Postpartum interventions, n (%)*,** Delivery satisfaction (DSS), sum, mean ± SD*** Positive delivery experience (>75th percentile of the DSS), n (%)*** W-DEQ-B score, mean ± SD****

CS, caesarean section; DSS, delivery satisfaction scale; SD, standard deviation; VE, vacuum extraction; W-DEQ-B, Wijma Delivery Experience Questionnaire. *Vaginal deliveries only. **Suturing of deep lacerations or surgical evacuation of placenta or membranes postpartum. ***Answered by 83 women in intervention and by 136 women in the control group. ****Answered by 77 women in intervention and by 124 women in the control group.

(DSS in the highest quartile) compared with control women [30 (36.1%) versus 31 (22.8%), P = 0.04]. Further, women in the intervention group had a significantly lower W-DEQ-B score, also indicating a more positive childbirth experience (Table 4). DDS and W-DEQ B show a strong negative correlation (Pearson correlation k = –0.782).

Discussion

Figure 2. Delivery mode: intervention group compared with control group (percentage of deliveries). The groups differed at P = 0.05 in rates of caesarean section (CS), P = 0.16 in rates of vacuum extraction (VE) and P = 0.005 in rates of spontaneous vaginal delivery (SVD).

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This randomised study reveals that, through group psychoeducation, it is possible to influence the mode of delivery and childbirth experience of nulliparous women with a severe fear of childbirth. We gathered the study population by screening for fear of childbirth in early pregnancy, and randomised those with severe fear of childbirth (8.1% of all nulliparous women) to either psychoeducative group therapy or surveillance groups. Women with severe fear of childbirth who participated in our study group chose and managed to have vaginal delivery significantly more often than women without group therapy. Altogether 87.8% of

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

Treatment of women with fear of childbirth

Table 5. Delivery mode and other birth information comparing women who participated in intervention (n = 90) with women who received special support or care because of fear of childbirth (n = 106) (the difference between the groups was tested by t-test for parametric variables and chi-squared test for categorical variables) Variable

W-DEQ-A score, mean ± SD VAS, mean ± SD VAS ‡ 5, n (%) Gestational age at delivery (weeks), mean ± SD Delivery mode Spontaneous vaginal, n (%) VE, n (%) CS, n (%) CS because of fear of childbirth, n (%) Other elective CS, n (%) Emergency CS, n (%) Epidural or spinal analgesia, n (%)* Bleeding (ml), mean ± SD Stage I (minutes), mean ± SD* Stage I (hours), mean ± SD* Stage II (minutes), mean ± SD* Birthweight (g), mean ± SD pH 0.99

59 (65.6) 10 (11.1) 21 (23.3) 11 (12.2) 0 (0) 10 (11.1) 60 (87.0) 567 ± 547 592 ± 287 9.4 ± 4.7 36.7 ± 36.4 3513 ± 552 5 (5.6) 8 (8.9) 12 (17.4) 30.0 ± 5.9

50 (47.2) 15 (14.1) 41 (38.7) 24 (22.6) 2 (4.9) 15 (15.1) 55 (85.9) 652 ± 658 687 ± 347 11.0 ± 5.8 30.7 ± 19.4 3488 ± 509 4 (4.2) 10 (9.4) 10 (15.4) 28.4 ± 7.2

0.01 0.67 0.03 0.06 0.50 0.67 0.42 0.35 0.10 0.11 0.26 0.74 0.74 >0.99 0.82 0.19

23 (35.4)

15 (26.3)

0.19

63.5 ± 32

68.4 ± 29

0.31

CS, caesarean section; DSS, delivery satisfaction scale; SD, standard deviation; VAS, visual analogue scale; VE, vacuum extraction; W-DEQ-A/B, Wijma Delivery Expectancy/Experience Questionnaire. *Vaginal deliveries only. **Suturing of deep lacerations or surgical evacuation of placenta or membranes postpartum. ***Answered by 65 women in intervention and by 57 women in the control group. ****Answered by 63 women in intervention and by 52 women in the control group.

women who participated in our study group chose to have vaginal delivery compared with 77.4% of women who had conventional treatment for fear of childbirth. Although the difference in the rates for CSs on maternal request did not reach statistical significance (P = 0.06), a significant difference was seen in total CS rates. Overall, CS on maternal request was not as frequent (12.2% for group therapy and 22.6% in controls) as suspected based on previous studies, where 21–49% of patients received an elective CS in spite of treatment.11,22,23,25 This could be because, in our hospital area, we have paid attention to this problem and have trained obstetricians and midwives to take care of women with fear of childbirth. Overall, the NNT showed that, by conducting psychoeducative therapy in one group of six

fearful women, we can avoid one CS compared with conventional care. It must also be kept in mind that, in this study, control women also received some type of treatment for their fear if needed. One-third of control women were sent to a maternity outpatient clinic for consultation because of fear of childbirth and 15% of control women attended special childbirth classes. Among the whole control group, those control women who were referred for consultation suffered from stronger fear than those who were not referred. However, their fear was not stronger than the fear of those participating in group therapy. The majority of control women with fear of childbirth were taken care of by nurses in primary healthcare maternity units. It would have been

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unethical to perform a randomised study comparing group therapy treatment with a pure nontreatment group. Therefore, we ran two different analyses: first, on the intentionto-treat-principle and, second, between all those who received any kinds of treatment for their fear of childbirth. In both analyses, the psychoeducative group therapy showed superiority over the two types of control group. However, in such clinical situations, where obstetricians only discuss CS on maternal request, but leave the fear itself unaddressed, fearful women are left without appropriate treatment.30 It is actually very natural for women to have fearful feelings towards childbirth, because it is a uniquely unpredictable and painful life experience. Childbirth also carries serious risks for the mother and child, even though this risk is small in Western countries.14,15,31 However, the risks of complications are more frequent in CS.13–15,30,32,33 In Finland, the total CS rates have risen to 16.3% (www.stakes. fi/EN/tilastot/statisticsbytopic/reproduction/deliveriesand birthssummary.htm), but remain far below the rates in, for example, Italy (33%),34 Chile (40.0%)35 or China (46.2%).36 CS is seldom a solution to fear of childbirth. Most women can cope with fearful feelings, but some women need professional help in order to manage pregnancy and delivery without mental trauma.11,22,23 Fearful women should be encouraged to confront their fears and receive support for vaginal delivery. In confronting their fears during pregnancy, women learn to accept insecurity, which might improve their self-confidence37 and possibly also their mental health later in life.26 Previous descriptive studies have shown good results in reducing requests for elective CSs for fear of childbirth by 50–85% when treating women with fear of childbirth in various ways,11,22–24 and our study was in accordance with these investigations. Group psychoeducation also increases the probability of uneventful spontaneous vaginal childbirth, as shown in this study. As shown in many studies, there is an increased risk of post-traumatic stress symptoms or disorder (PTSD) after emergency delivery operations.38– 40 Further, fear of childbirth is one of the major predisposing factors for post-traumatic stress reactions or PTSD after childbirth.8,36 Thus, the exposure of vulnerable fearful women to adverse obstetric outcomes puts them at remarkable risk for later development of PTSD. The important role of group therapy is to share different and often contradictory feelings towards delivery and parenthood in the group to normalise and diminish feelings of inferiority and indignity. By supporting pregnant women to deal with and accept different emotions and possible setbacks during pregnancy and childbirth can help them to prepare for a normal delivery without severe fear, making a positive delivery experience possible.26 By relieving anxiety and fear,

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the risk for both emergency CS and vacuum extraction can be reduced, and therefore the risk for PTSD can also be decreased. This new randomised study strengthens the knowledge of the effect of group therapy and, in further research, we will examine the puerperal psychological wellbeing of the women in this study. It is possible to generalise these results to all western countries. The group therapy outline is already presented here and a more specific manual is available. In addition, the fear of childbirth, pregnancy worries and uncertainty with regard to new parenthood are quite similar among women in all western countries. Fearful women receiving antenatal counselling for fear of childbirth have been shown to escape the negative childbirth experience regardless of the delivery mode,12 and this study also reveals the greater possibility of having a positive delivery experience with psychoeducative group therapy than with conventional care. According to clinical experience, a positive delivery has a far-reaching influence on a woman’s life. There are some limitations to our study which should be kept in mind before generalising the results. First, a higher DSS return could have given more reliable results for delivery satisfaction. Therefore, the trend may be further strengthened in subsequent studies. Although we could not get delivery satisfaction from every participant, the birth information is from obstetric patients, records and therefore from everyone. Second, the participation in group therapy was slightly lower than expected, but similar to that in our previous study.23 We must accept that group therapy is not suitable for everyone. However, through public education, we could achieve higher participation rates by lessening the shame that many associate with psychological care. Third, anxiety and depression were not measured at the start of the study, even though they have been shown to increase the prevalence of fear of childbirth and can be expected to influence the results of treatment. However, this was a clinical study in an obstetric department and we wanted to focus on the obstetric outcome.

Conclusions Fear of childbirth complicates many pregnancies and deliveries as, overall, 8.1% of screened nulliparous women scored for severe fear of childbirth. To decrease the numbers of CSs, both elective and emergency, it is very important to treat women with fear of childbirth appropriately. This randomised study showed the marked effect of psychoeducative group therapy for the treatment of nulliparous women with fear of childbirth, as significantly more women who received this treatment had spontaneous vaginal delivery and were also more satisfied with their delivery.

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

Treatment of women with fear of childbirth

Acknowledgements We thank Emil Aaltonen and the Signe and Ane Foundations for the support they gave to this study.

Disclosure of interests No conflicts of interest exist.

Contribution to authorship All the authors planned the study. HR and TS organised the clinical part of the study. MT and RT led the psychotherapeutic sessions and coached two other psychologists to this purpose. HR organised and analysed the data, and wrote the first version of the article. TS and KS-A helped with the analysis. All the authors contributed equally to further revision of the manuscript and approved the final version.

Details of ethics approval This study received ethics approval from the Ethical Committee of Obstetrics and Gynaecology (Ethical Approval Number 376/ E9/059). Informed consent was collected from all participants.

Funding Funding was arranged by grants from the Emil Aaltonen Foundation and the Signe and Ane Gyllenberg Foundation. Researchers have no connections to the founders and the founders had no other role than funding in this study.

Trial registration Clinical Research Register at Helsinki University Central Hospital Number: 228/2006 and ClinicalTrials.gov ID: NTC01548131. j

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