Where Is Havinfg a Baby on the Pain Scale Where Is Having a Baby on the Pain Scale

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• Published: 24 June 2012

The influence of women's fear, attitudes and beliefs of childbirth on mode and experience of birth

BMC Pregnancy and Childbirth volume 12, Article number:55 (2012) Cite this article

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Abstract

Background

Women's fears and attitudes to childbirth may influence the maternity intendance they receive and the outcomes of birth. This report aimed to develop profiles of women according to their attitudes regarding nativity and their levels of childbirth related fear. The association of these profiles with fashion and outcomes of nativity was explored.

Methods

Prospective longitudinal cohort design with self report questionnaires containing a gear up of attitudinal statements regarding birth (Birth Attitudes Profile Scale) and a fear of nativity calibration (FOBS). Significant women responded at eighteen-20 weeks gestation and two months after birth from a regional area of Sweden (n = 386) and a regional area of Australia (due north = 123). Cluster analysis was used to identify a set up of profiles. Odds ratios (95% CI) were calculated, comparing cluster membership for country of care, pregnancy characteristics, nativity experience and outcomes.

Results

Three clusters were identified – 'Cocky determiners' (articulate attitudes about birth including seeing information technology equally a natural process and no childbirth fearfulness), 'Take it every bit it comes' (no fear of birth and low levels of understanding with any of the attitude statements) and 'Fearful' (afraid of birth, with concerns for the personal touch on of birth including pain and command, safety concerns and low levels of agreement with attitudes relating to women's freedom of choice or birth every bit a natural procedure). At 18 -20 weeks gestation, when compared to the 'Self determiners', women in the 'Fearful' cluster were more likely to: adopt a caesarean (OR = three.3 CI: i.six-6.8), concord less than positive feelings about being meaning (OR = 3.6 CI: 1.4-9.0), report less than positive feelings about the approaching birth (OR = 7.2 CI: 4.4-12.0) and less than positive feelings almost the get-go weeks with a newborn (OR = two.0 CI 1.two-three.6). At two months post partum the 'Fearful' cluster had a greater likelihood of having had an elective caesarean (OR = five.4 CI 2.one-14.2); they were more likely to take had an epidural if they laboured (OR = ane.9 CI 1.1-3.ii) and to feel their labour pain as more intense than women in the other clusters. The 'Fearful' cluster were more probable to report a negative experience of nascence (OR = 1.seven CI 1.02- 2.9). The 'Have it equally information technology comes' cluster had a higher likelihood of an elective caesarean (OR iii.0 CI one.1-8.0).

Conclusions

In this study three clusters of women were identified. Belonging to the 'Fearful' cluster had a negative effect on women's emotional health during pregnancy and increased the likelihood of a negative birth feel. Both women in the 'Take it as information technology comes' and the 'Fearful' cluster had higher odds of having an elective caesarean compared to women in the 'Cocky determiners'. Understanding women'southward attitudes and level of fear may help midwives and doctors to tailor their interactions with women.

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Background

Understanding and responding to women's beliefs and attitudes during the childbearing period is an important focus of international motherhood wellness policy. The terms 'woman centred care' and 'informed pick' reflect that in addition to the physiological aspects of pregnancy and birth, in that location are psychological, psychosexual, and psychosocial aspects unique to the individual life experiences of pregnant women. These must be considered in order to optimise a woman's birth outcomes and experience [one]. The psychosocial wellbeing of women is at present viewed every bit equally important every bit her concrete wellbeing [2].

In a 'adult female centred' arroyo the clinician moves across medico/protocol/risk centric care and seeks to better empathise the private woman through ascertaining her attitudes to pregnancy and birth and her particular life situation [3]. Attitudes have been conceptualized using a three-component model: affective, cognitive and behavioural [4]. The affective component consists of positive or negative feelings toward the attitude object; the cognitive part refers to thoughts or behavior; and the behavioural element represents the deportment or intentions to human activity upon the object. Social psychologists differentiate a belief from an attitude by suggesting that a belief is the probability dimension of a concept – 'is its existence probable or improbable?'[5] An attitude on the other paw, is the 'evaluative' dimension of a concept. 'Is it proficient or is information technology bad?' [5]. A change in attitude toward a given concept can result from a change in belief about that concept [5].

The 'Harsanyi Doctrine' [6] asserts that differences in individuals' behavior can be attributed entirely to differences in information [7]. Applying this doctrine to maternity care, information technology is interesting to consider where, what, how and past whom, information is shared between women and their care givers and what impact this may have on their beliefs and attitudes. A recent study of i,318 depression-risk Canadian women conducted by the University of British Columbia and the Kid & Family Enquiry Constitute [8, nine] illustrates this point. Focusing on attitudes to nativity technology, the Canadian study reported that women attention obstetricians were more favourable to the use of nascency applied science and were less appreciative of women's roles in their own birth. In dissimilarity, women attention midwives reported less favourable views toward the utilise of applied science and were more than supportive of the importance of women'due south roles. Family practice patients' opinions fell between the other two groups. These women could be a self selecting population who choose a particular care giver according to their pre-existing attitudes, or alternatively the attitudes of the women could be influenced by the information they receive from their caregiver.

The determinants of a adult female'southward attitudes and beliefs are inherently linked to cultural and health system specific influences [10]. In run a risk-averse biomedical systems of care the woman's attitudes and beliefs about nativity may determine the level of intervention that she actively chooses or passively receives. With the aim of examining changes over time (1987-2000) in women'southward expectations and experiences of intrapartum care, the Greater Expectations Study [11] surveyed approximately 1400 significant women across several wellness services in the United Kingdom (United kingdom). It demonstrated that women'due south attitudes and expectations had shifted over the 13 year period from when the original report [12] had been undertaken. The findings showed a relationship betwixt childbirth outcomes and women'due south antenatal attitudes. The issue of greatest concern to the authors was the increase in women's antenatal anxiety nigh pain and their reduced organized religion in their power to cope with labour [xi]. Over the aforementioned time period in that location was an increased use of obstetric interventions, specially consecration, epidurals and caesarean sections. Mean scores on a scale designed to measure out a willingness to accept interventions ('attitude to intervention') were significantly higher in 2000 than in 1987. Women who went on to have unplanned caesarean sections or assisted deliveries had significantly higher 'mental attitude to intervention' scores antenatally than women who went on to take unassisted vaginal deliveries. The study suggested that an explanation for this was an increased employ of epidurals by women who were positive about interventions [13]. In 2001 an inspect report was tabled in the UK as an investigation of the patterns of, and the reasons for, caesarean [14]. This report included women'southward responses to a range of attitudes and beliefs about childbirth. The findings indicated that women who preferred caesarean as the mode of birth held attitudes reflecting a conventionalities that birth was not a natural process and that they were concerned near control and pain and rubber.

In clinical practice 'woman centred care' and 'informed choice' take manifested in such practices equally the distribution of evidenced based information brochures, client-held medical records, birth plans and formal screening for psychosocial pathology- in particular perinatal depression and domestic violence [15–xix]. Despite the rhetoric, women's individual circumstances, attitudes, beliefs and choices are not necessarily at the centre of the decisions made in regard to her intendance. The term 'woman centred care' is not a commonly used term in Swedish maternity policy. Women's personal autonomy is politically of import, but the concept of 'informed choice' is express by the State– for example nether the universal land funded health system women have no freedom to cull their model of maternity intendance nor mode of nativity [20]. In Australia, option is oftentimes limited by the region where a adult female accesses care [21].

In addition to the diagnosis of perinatal depression, researchers and clinicians are increasingly recognising the importance of pregnancy-specific feet, with fright of childbirth existence a sub construct of this anxiety [22]. A clinically meaning fear of childbirth is estimated to touch on twenty to 25% of meaning women and the prevalence of severe fearfulness that impacts on daily life is thought to be between six and 10% [23–31]. Most of the literature regarding childbirth fear has been focused on Scandinavian populations, yet childbirth fear crosses cultural boundaries every bit studies from Australia [28, 29], the Britain [30], Switzerland [31], Usa [32] and Canada [23] attest. In an endeavor to sympathise a adult female's attitude or belief near nascency it is important therefore to add the impact of fear to proceeds a fuller picture.

In 1985, Raphael-Leff published profiles of pregnant women [33] where she described mothers in iv categories: 'Facilitator', 'Regulator', 'Reciprocator', and 'Conflicted' (Table ane). Her model, which is based on her extensive clinical experience, mother-child observations and survey data, postulates that in that location is a variety of approaches to pregnancy and early maternity inside and betwixt societies. She describes these as 'orientations' and, while other studies take linked particular personality traits to phenomena such equally a request for caesarean for not medical reasons [34], Raphael-Leff states conspicuously that her model is not most personality traits. Dissimilar pregnancies and differing circumstances mean that a woman's orientation may change with each gestation [33, 35].

Tabular array 1 Raphael- Leff Orientations

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A contempo prospective study from Belgium [36], attempted to predict a woman'south childbirth experience using antenatal expectations of nascency and the Raphael-Leff model of orientations. While the antenatal expectations of the women conspicuously predicted their postpartum recollection of intrapartum experiences, the study did non support the contained contribution to birth experience of the Raphael- Leff orientations later on obstetric complications were taken into account. At that place was a proffer however, that maternal orientations made some contribution to the childbirth experience.

To assistance clinicians in their efforts to sensitively and effectively place women at the centre of maternity care, more cognition is required nearly how women remember about birth and the extent to which they are fearful. Farther empirical inquiry therefore is needed to better empathize attitudinal profiles in significant women and the clan this has with their pregnancy outcome and feel.

In this report we aimed to identify profiles of pregnant women based on their attitudes to and beliefs almost nascency and their levels of childbirth related fear. Nosotros aimed to compare pregnancy characteristics, outcomes and experiences of birth between these profiles. Our hypothesis was that women with an elevated fear of birth would emerge equally a distinct profile that had poorer pregnancy and birth outcomes than other women.

Method

This prospective cohort study is part of a broader longitudinal investigation of aspects of pregnancy, nascency and early parenting. The data collection constitutes a sample of rural and regional women in Sweden and Commonwealth of australia undertaken during the years 2007 – 2009.

Participants

The Swedish cohort was drawn from a regional surface area in the province of Vasternorrland and the Australian accomplice came from a northeast regional area in the land of Victoria. Both sites have an annual birth rate of around five hundred per year and a largely homogenous population of non immigrant women. The Swedish group was recruited at routine ultra sound screening in pregnancy calendar week 17-xix. Almost all women undertake this examination in Sweden [37], making it an ideal time to admission potential participants. A letter with information nigh the written report was sent two weeks prior to the test. Swedish speaking women with a normal ultrasound were approached by a recruiting midwife and asked if they wanted to participate in the study. The questionnaire was either filled out at the ultrasound ward, or completed at dwelling house and returned by a paid postal envelope. In the Australian setting, all women who requite nascence at the local infirmary attend a booking with a midwife at the antenatal dispensary between 18 -xx weeks gestation. At this visit those women who were English speaking with a normal 18 calendar week ultrasound effect (thus reducing the chances of women with serious foetal anomalies being sent questionnaires) were invited to take part in the study by the booking midwife. Those who agreed received written information, signed a consent grade, and were given a questionnaire to either complete on the spot, or accept home and return in a answer paid postal envelope. Reminder messages were posted on two occasions to non responders in both settings.

Ideals approval was obtained from respective regional ethics committees in northern Sweden and Wangaratta, Australia too equally from the Mid Sweden University, and The University of Melbourne.

Questionnaires

Information was collected using self report questionnaires as part of a larger study, investigating women'south' experiences of pregnancy and birth. In the study reported here information is from xviii -twenty weeks gestation and ii months subsequently birth. This report includes information from women who answered questions at both time points.

The questionnaire at 18-twenty weeks measured attitudes and beliefs regarding birth by determining the force of women'southward agreement/disagreement on a six-point rating scale to twelve personal and four general statements which had been used previously in ii large studies from the United kingdom [14, 38]. The sixteen attitudinal items were subjected to gene analysis – reported in a previous study [39]. 4 subscales were identified: 'Personal impact of nativity', 'Nascency every bit a natural outcome', Liberty of option' and 'Safety concerns'. As the four subscales are short (less than ten items) the internal consistency of the subscales were assessed using hateful inter-item correlations as recommended by Briggs and Cheek [40]. These ranged from 0.31- 0.40 indicating very good internal consistency. The items and reliability statistics of each subscale are shown in Tabular array two.

Tabular array two Nascence Attitudes Profile Scale

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Total scores for each subscale were calculated by adding together the scores for the individual items. Loftier scores indicated strong agreement. The subscales generated from the set of attitudinal items will be referred to throughout the remainder of this manuscript as the Birth Attitudes Profile Calibration (BAPS).

Childbirth fear was too measured at 18 -20 weeks, using a Fear of Birth Scale (FOBS) [29]. Women were asked to reply to the question 'How do you feel right now about the approaching birth?' by marker two 100 mm VAS-scales anchored by the words: worried/ calm, and potent fear/no fear. These two scores were averaged to give a full score. The FOBS demonstrated excellent internal consistency, with a mean inter-particular correlation of 0.84.

The other questions in the questionnaire were drawn from previous population based studies of women's experiences of pregnancy and nativity conducted in Australia and Sweden [41, 42]. Five-signal Likert scales were used to determine physical wellness, emotional wellness and previous birth experience. Women'due south feelings about the approaching birth and the new-built-in were measured by their response to the questions: "How do you feel about the budgeted birth?" and: "How do you experience when thinking almost the first weeks with a new-built-in baby?" V response alternatives ranged from 'Very positive' to 'Very negative' with a middle pick of 'both positive and negative'. Responses to all the Likert scales were dichotomised to reverberate 'positive' or 'less than positive'. Nascency preferences were ascertained by request the question "If you lot had the possibility to choose, how would y'all prefer to give nativity", with the response alternatives 'Vaginal birth' and 'Caesarean'.

Women were asked at ii months post partum about their mode and experiences of birth. These questions had been previously used in Australian and Swedish studies [41, 42]. They were asked to bespeak the length of their labour in hours by answering the question "How many hours did your labour last?" Their perception of labour pain was explored by the questions: "How much pain did you feel during labour?" and "How did you experience this pain?" This was assessed by marking two seven bespeak scales anchored with the phrases 'no hurting at all (1)' to 'worst pain imaginable (vii)' and 'Very Negative' (7) to 'Very Positive' (1).

Assay

Statistical analysis was conducted using SPSS for Windows Chicago, IL, U.s.a. Version 17. Characteristics of the women from both cohorts were compared using chi square tests. A cluster assay was conducted on responses to the BAPS and the level of fear, every bit determined by the FOBS [29]. Every bit cluster assay is very sensitive to outliers [43], the data was screened and three outlying cases were identified and removed. These cases independent fear scores at the extreme end of the calibration and 'not thought about' responses to all attitudinal questions. Consequent with the procedures described by Shannon [43], a Kappa-hateful cluster analysis, forcing a three cluster solution, was applied to z-score transformed responses to each of the four BAPS subscales and the FOBS mean score. Given the exploratory nature of cluster analysis other possible solutions (e.g. ii-cluster, 4-cluster solutions) were too inspected. The three cluster solution was found to offering the nigh interpretable and clinically meaningful solution. Each cluster was named according to the grouping of its items after give-and-take and agreement from the authors that these names gave an accurate and easily understood meaning. Demographic characteristics of the three clusters were compared using chi square statistics.

The adjacent step was to calculate rough and adjusted odds ratios with 95% confidence intervals (CI) for the different explanatory variables during pregnancy and birth using the Mantel–Haenszel technique every bit described by Rothman [44]. Differences in the continuous data consequence variables measuring length of labour and feel of pain were compared beyond clusters. Due to diff group sizes and non-normal distributions this was calculated using the Kruskal Wallis test [44].

Results

Participation and response

Effigy ane shows that of the 530 women who were eligible from the Swedish sample, 519 were recruited, (98% of those eligible), 386 women returned the showtime questionnaire giving a response charge per unit of 74%. The Australian sample had 413 women eligible, 168 recruited (41% of those eligible) and 123 returns, making a response rate of 74% for the first questionnaire.

Figure 1

Participation and Response Rates.

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At two months post partum a follow-up questionnaire was sent to 386 Swedish women, after exclusion of two intrauterine deaths, one very sick baby, two who withdrew participation and 127 who did not respond to the two first questionnaires. Three hundred mail partum questionnaires were completed past the Swedish women. In the Australian cohort the post partum questionnaire was sent to 121 women after the exclusion of 45 women who did not respond to the start questionnaire, one foetal death and one participation withdrawal, leaving 91 women who responded.

Sample characteristics

The majority of women in both countries were 25 to 35 years former, married or cohabiting and were multiparas (Table iii). The socio demographic characteristics of both samples did not prove whatsoever statistically meaning differences in historic period, marital status, previous infertility, parity and instruction. The Australian cohort had significantly more women who had experienced a previous caesarean section; both emergency and constituent, while the Swedish accomplice had significantly more women who had previously had an instrumental nascence (Table 3).

Tabular array 3 Characteristics of women in regional cohorts of Commonwealth of australia and Sweden at 18 -twenty weeks gestation

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Cluster analysis

Effigy 2 shows the three clusters which were identified based on women's level of agreement to the BAPS items and their level of fearfulness on the FOBS. Cluster one 'Cocky determiners' were characterised by low fear and agreement with the attitudes relating to the personal affect of nascency, safety concerns, the natural process of birth and freedom of choice. Cluster 2 'Take information technology as it comes' were not afraid of childbirth. They indicated depression levels of agreement on all attitude items. Cluster 3, the 'Fearful', scored high on childbirth fear, showed moderate agreement to the items regarding the personal impact of nascency and some concern regarding safety. This group reported low levels of understanding with the items relating to the natural process of birth and to exercising free choice regarding mode of birth.

Figure 2

Clusters identified from z-score transformed responses to four attitudinal subscales and FoBs hateful score.

Total size prototype

Characteristics of clusters

Table 4 shows that the numbers of women in the Australian cohort were evenly spread beyond the 'Self determiners', 'Accept it equally it comes' and 'Fearful' clusters (32%, north = 37, 35%, north = 40, 33%, northward = 38 respectively), while the Swedish cohort had a comparatively less counterbalanced membership: 'Self determiners' (42%, north = 155), 'Accept it as information technology comes' (25%, due north = 90), and 'Fearful' (33%, n = 121). These differences in state of care on cluster membership did not quite reach statistical significance (p < 0.06). The socio-demographic and personal characteristics of each cluster were compared with no differences detected in historic period, marital status, parity or previous infertility. Women with a lower level of education however, were more likely to belong to the 'Self determiners' cluster (p < 0.003), while women who had experienced a previous caesarean were less likely to belong to this group (p < 0.001). Women with a previous negative nativity feel were more likely to vest to the 'Fearful' cluster (p < 0.001).

Tabular array four Characteristics of women in the three clusters at 18 -xx weeks

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Afterward aligning for age, country, pedagogy, and parity, Table 5 shows that the 'Fearful' cluster at 18-twenty weeks gestation were more than likely to have poorer cocky rated emotional health than the women in the 'Cocky determiners' cluster (OR = 3.3 CI 1.five-7.3). They were more likely to prefer a caesarean (OR = iii.3 CI: one.6-6.8) and more than probable to have less than positive feelings about being pregnant (OR = iii.6 CI: ane.4-9.0).This group of women were more probable to study less than positive feelings almost the budgeted birth (OR = 7.2 CI: four.4-12.0) and twice as probable to have less than positive feelings near the first weeks with a newborn (OR = 2.0 CI 1.ii-3.six).

Table 5 Self-rated health, nativity preference and feelings almost pregnancy, nascence and parenting in three clusters of women at 18 -20 weeks

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Table 5 shows that at mid pregnancy, the 'Take it equally it comes' cluster had a higher likelihood of having less than positive feelings nearly the beginning weeks with a newborn when compared with the 'Self determiners' (OR = 2.0 CI, ane.1-3.4) withal this was no longer significant when adjusted for age, country, education, and parity.

Birth outcomes

At ii months post partum Table 6 shows that the women classified in the 'Cocky determiners' cluster had the highest percentage of unassisted vaginal births: 44% (n = 113) compared with 27% (north = 67) in the 'Fearful' and 29% (north = 73) in the 'Have it every bit it comes' cluster (p <0.04). The 'Fearful' cluster had a greater likelihood of having an constituent caesarean (OR = 5.4 CI 2.one - 14.two) and college odds of having an epidural if they laboured (OR = 1.ix CI 1.ane-3.2). 'Fearful' women reported a higher likelihood of having received counselling during pregnancy for their fear of nascency when compared with the women in the 'Self determiners' cluster (OR = v.0 CI 1.9-13.2). Their likelihood of a negative birth feel was higher than for the women in the 'Self determiners' (OR = 1.7 CI 1.01-2.9). At ii months post partum (Table half dozen), the 'Have information technology as it comes' reported three times the likelihood of elective caesarean OR = three.0 (CI i.1-8.0) when compared to the 'Self determiners'.

Table half-dozen Nascence outcomes in the three clusters 2 months post birth

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After excluding women who had an elective caesarean, mean scores were calculated on length, intensity and feel of labour hurting beyond the clusters. The 'Take information technology as information technology comes' cluster reported a shorter length of labour (p < 0.005) than women in the other two clusters (Table 7). The 'Fearful' reported their labour pain as more intense than women in the other clusters (p <0.009). There was no deviation between the clusters in the women's experience of labour pain.

Tabular array 7 Length of labour, hurting intensity and pain experieince in women in the 3 clusters ^#

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Discussion

This cohort of Swedish and Australian women were categorised into three attitudinal profiles: 'Self determiners', 'Take information technology as it comes' and 'Fearful'. Comparison of the women within these clusters revealed differences in emotional health, nativity preferences, and feelings most being significant. They too showed pregnant differences in a number of birth outcomes. Of these iii profiles, the presence of fear had the virtually negative touch on on women's emotional health, feelings about pregnancy and parenting and experience of nascency. Belonging to the 'Fearful' cluster increased a woman's likelihood of preferring, and really having, an elective caesarean.

'Fearful' cluster

The 'Fearful' women were characterised by high levels of fear and concerns regarding safety. These women were worried about the personal impacts of birth such as pain, their sense of control and whatsoever detrimental effects nascency may have on their body. These women did not see birth every bit a natural issue and did not subscribe to an attitude of freedom of option. Their likelihood of preferring a caesarean was three times that of women in the 'Self determiners' cluster. This resonates with the Raphael-Leff's description of the 'Regulator' cluster of mothers [33, 35, 45].

This finding was also consequent with the results of the Thomas and Paranjothy report [14] which described women who preferred a caesarean equally more probable to place a loftier priority on their own safety and being as hurting free as possible. Likewise, Thomas and Paranjothy showed that women [14] who preferred caesarean were more likely to disagree with the statement that 'birth was a natural process that should not exist interfered with unless necessary' - an attitudinal item included in this 'Fearful' cluster group.

It was not surprising to discover that the 'Fearful' cluster independent significantly more than women with a previous caesarean and a previous negative birth experience. These are well known determinants of childbirth fear [46, 47]. Belonging to the "Fearful' cluster increased the likelihood of women actualising their preference for an elective caesarean. This higher prevalence of constituent caesarean has been described in the literature previously on childbirth related fear from the Nordic populations [42].

Women in the 'Fearful' cluster had poorer cocky rated emotional health in mid pregnancy than women in the other clusters; a finding that points to them being at hazard of poor mental wellness both in the perinatal period and possibly beyond [48]. Women with childbirth related fear are agape of inadequate support, disability to contribute to of import decisions apropos themselves or their babe, losing control and 'performing' badly [24–28, 31, 46, 47]. These characteristics once more show similarities with Raphael-Leff's 'regulator' group who meet vaginal birth every bit a potentially humiliating experience [35].

Fear is commonly articulated as fear of unbearable hurting, fear for their own and their infant'south safety and fearfulness of obstetric injuries [47]. Women in this cluster reported more negative birth experience than the other clusters. Peradventure inherent in their negative experience of birth, was our finding that the 'Fearful' cluster of women perceived their labour as more than painful than the women in the other clusters. Our findings demonstrated that the 'Fearful' cluster had a higher use of epidural. Pain in labour is a complex event. Despite widespread use of powerful analgesics and modern anaesthetic techniques, many women report high levels of pain with some describing information technology as the 'worst hurting imaginable' [49]. Alleviating pain does not guarantee an improvement in women'due south experience of labour or their longer term recollections of hurting [50].

'Self determiners' cluster

Overall the 'Self determiners' cluster contained the highest proportion of women. These women showed house opinions on a range of attitudes and beliefs. They were non afraid of childbirth. These women had the highest percentage of unassisted vaginal nascence.

The 'Cocky determiners' were less educated than women in the other two clusters. This finding is in dissimilarity to the media prototype of the savvy, believing highly educated adult female holding articulate views about the blazon of birth she wants [51]. Likewise it contrasts with the generalisations created by some healthcare professionals who perceive lower educated women every bit being less informed and less interested in making choices regarding their intendance. Dark-green et al [52] reported that, contrary to the stereotypes of pregnant women generated by caregivers, the less educated women did not desire to mitt over all control to the staff and had the highest expectations for a fulfilling birth experience Our findings are commensurate with this.

'Take it as it comes' cluster

The women in the 'Take it every bit it comes' cluster were not afraid of childbirth but they appeared to have no house attitudinal preferences concerning birth. The 'Take it as information technology comes' were no more likely to have preference for either vaginal or caesarean birth than the 'Self determiners', however when bodily way of birth was compared, the 'Take it as it comes' group had an increased likelihood of elective caesarean. We might postulate that these women will simply 'go with the flow' every bit described by Pilley Edwards [53]. The reluctance of some women to engage in autonomous obstetric controlling has been described and explained in regard to actively choosing mode of birth [38]. Many women feel unable or unwilling to exercise selection regarding mode of birth as any determination is ever governed by what is best for the baby in the particular circumstances they observe themselves in [38].

This approach is in keeping with Lehman's (1950) 'Decision Theory' equally cited by Lie [54] where "there is a certain relationship between a rational person's preferences for acts, probability assignment for states and utility assignment for consequences [54]". Information technology follows that given nigh women agree strongly with the paramount importance of condom of the baby, that this 'Take it as information technology comes' grouping would be especially vulnerable to acceding to an intervention that was in any mode couched with linguistic communication promoting baby wellbeing. This cluster of women show some characteristics in common with Raphael-Leff'southward 'reciprocator' orientation who do not accept a precise nativity 'program', instead holding a 'wait-and-run across' attitude regarding the childbirth [33].

Clinical implications

Knowing that information shapes beliefs and can atomic number 82 to attitude changes [v, 6], midwives and doctors have an of import role in influencing positive, salubrious attitudes to nascency in women by providing clear, evidence based information. In caring for women who fit the 'Fearful' cluster the findings of this study tin help clinicians to focus on raising word about the personal bear upon of nativity. In item, discussion and planning should address women's feelings about control and pain. Debunking myths and providing clear communication about risk and safety ought to be a feature of antenatal intendance. Clinicians have an opportunity to reinforce the natural aspects of the pregnancy and nascency feel. Understanding the complexities of the underlying attitudes and fears women bring with them to the antenatal encounter or birthing room can enable maternity-care professionals to interact in a sensitive and meaningful way with women.

Midwives and doctors are in a unique position to develop a trusting insightful relationship with the women they encounter. In beingness enlightened of women's fears in detail, midwives and doctors and so must be sensitive to anxieties which can be approached with reassurance, information and i to 1 support. While the role of specific counselling for fearfulness of childbirth has not been shown to 'cure' fearfulness [55, 56] clinicians must remain warning to women with serious distress requiring referral for good psychological help.

Women in the 'Accept it as it comes' cluster may also warrant further attending from clinicians. This group are most likely the women who antenatally seem to have no issues. This group of women could benefit from clear information regarding the potential impacts of intervention on them and their baby. They could be encouraged to take a more than proactive arroyo to giving birth with confident encouragement from their clinician. With clear explanations and guidance from clinicians these women may be potentially positioned to avoid unnecessary intervention.

Limitations

This study focused on women from ii regional areas in Sweden and Commonwealth of australia and, as such, the findings should be interpreted with some circumspection in terms of generalisablity to other populations. The potential to discover a difference in cluster membership by country of care may take been express by the relatively depression numbers of participants in the Australian accomplice. The participation charge per unit in the Australian setting may accept been linked to the context of the booking appointment where the women were invited to participate. At this visit the adult female may well have been subject field to information overload every bit she is given health promotion data, referrals for blood tests, clinic appointments and antenatal education course information. The burden of completing a questionnaire on top of this may accept been too much for some women.

Additional research is needed on a larger number of women to observe if there are systematic differences between the two countries. Farther replication of the results of this report across other populations is also needed to confirm their stability, particularly given the exploratory and subjective nature of cluster analysis.

Option bias is a common problem in the recruitment of participants to cohort studies, every bit is loss to follow up with a longitudinal design. This written report excluded women who were unable to speak the native language of their respective country of care and therefore limited the study'due south capacity to explore a more diverse set of opinions and attitudes. Both regional centres are however characterised past low numbers of foreign born women.

The BAPS adopted for this written report has shown iv subscales measuring attitudes [39] with good internal consistency. The items which found the calibration have been used in ii previous British studies [14, 38]. Although the use of a defined prepare of attitudes limits our ability to identify other salient beliefs that may be relevant, it does allow the responses to be scored then clustered and compared across groups in a consistent style. The prospective design of this written report ensured that attitudes were measured during pregnancy, thereby avoiding the potential problem with recall bias.

Decision

In this Australian and Swedish written report, 3 clusters of women were identified based on attitudes held during mid pregnancy. Belonging to the 'Fearful' cluster had a negative consequence on women'southward emotional health during pregnancy and increased her likelihood of an operative nascency and a negative nativity experience. Women in the 'Take it equally it comes' cluster were identified equally a vulnerable group for an operative birth. The results of this written report suggest that attitudes and childbirth related fright are of import factors related to nascence effect that should be explored by wellness professionals during the antenatal menstruum. Midwives and doctors can assist women in their preparation for birth past spending time sensitively enquiring about their feelings and attitudes toward pregnancy. Working towards a positive experience of birth is one of the most crucial goals the health team must set. Most peculiarly midwives and doctors must discuss any fears the women may take. Noesis about women'due south attitudes may assist midwives and doctors to tailor their interactions with women in such a way as to inform and reassure them in their chapters to give birth and become a mother. The utilise of this profiling approach on a larger cohort of women is recommended for farther inquiry.

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Acknowledgements

The women and midwives from Wangaratta & Örnsköldsvik for their time. The Canton council of Västernorrland, Sweden, The Swedish Inquiry Council, Stockholm Sweden, Mid Sweden University, Sundsvall Sweden, The University of Melbourne, University Section of Rural Health, Australia for funding support.

Author information

Affiliations

1. Section of Women's and Children's Health, Obstetrics and Gynaecology, Uppsala University, 751 85, Uppsala, Sweden

   Helen Chiliad Haines, Christine Rubertsson & Ingegerd Hildingsson

2. Rural Wellness Academic Eye, University of Melbourne, 49 Graham St, Shepparton, Victoria, Australia

   Helen M Haines & Julie F Pallant

3. Department of Wellness Science, Mid Sweden University, Sundsvall, Sweden

   Ingegerd Hildingsson

4. Department of Women's and Children's Health, Division of Reproductive and Perinatal Healthcare, Karolinska Institutet, Stockholm, Sweden

   Ingegerd Hildingsson

5. Northeast Wellness, Green St., 3677, Wangaratta, Victoria, Australia

   Helen M Haines

Corresponding author

Correspondence to Helen Grand Haines.

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Competing interests

The authors declare that they take no competing interests.

Authors' contributions

HH, IH conceived of the report, developed the study instrument and undertook data collection. HH participated in the study blueprint, performed data edits and statistical analyses, wrote the draft, and reviewed and finalized the manuscript. IH participated in the study design, performed information edits, statistical analyses and edited and reviewed the concluding manuscript. JP participated in the report design, performed data edits, statistical analyses and edited and reviewed the final manuscript. CR participated in the study blueprint, reviewed the study instruments and edited and reviewed the manuscript. All authors read and canonical the final manuscript.

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Haines, H.M., Rubertsson, C., Pallant, J.F. et al. The influence of women'south fear, attitudes and beliefs of childbirth on style and experience of nascency. BMC Pregnancy Childbirth 12, 55 (2012). https://doi.org/x.1186/1471-2393-12-55

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• Received: 23 December 2011

• Accepted: 14 June 2012

• Published: 24 June 2012

• DOI : https://doi.org/10.1186/1471-2393-12-55

Keywords

• Pregnancy
• Attitudes
• Childbirth fright
• Cluster analysis
• Calibration

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