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Why fear of childbirth must be studied in the US

Approximately four million women give birth each year in the United States. Most women have some level of fear about labor and birth; it is considered part of the normal experience of childbirth.

For some women, that fear may be about whether she and the baby will be healthy. Other women may fear that their health care providers are not going to treat them with respect or kindness. While many women are able to cope with it, for some women this fear is more difficult to manage and may impact their birth.

As a midwife and clinical assistant professor in nursing, I wanted to explore what we actually knew about fear during childbirth and its effects on outcomes for women and their newborns in the United States. The answer: not much.

Research about fear of childbirth in the U.S. is limited

Research from Scandinavian countries demonstrates that from 5-20 percent of women have significant fear of childbirth. Other research from Scandinavia has found that women with fear of childbirth experience longer and more challenging labor, are more likely to need medication to make progress, may need to have more cesareans, have more dissatisfaction with their birth and take longer to adjust after their birth.

However, because most of the research about fear of childbirth comes from Scandinavia, this research does not provide a lot of insight into what is happening in the United States. Scandinavian countries have very different health and maternity care systems.

So what does the research say about fear of childbirth here?

One small study says potentially as many as 50 percent of women in the U.S. experience significant fear of childbirth. But that study is one of just three on fear of childbirth in the U.S. These studies mostly included well-educated white women, which limits how much information they give us about the rest of the population in the United States.

Our disjointed maternity care system is the likely reason so little research on fear of childbirth has been done in the U.S. While obstetricians and midwives consider the emotional needs of women to be an important part of health and wellness during pregnancy, the length of prenatal care visits and the expectation for high-volume practices mean that very few clinicians are actually spending the time addressing psychosocial concerns of pregnancy, like fear of childbirth.

A woman has her stomach measured by a nurse practitioner as she receives a prenatal exam. Joshua Lott/Reuters

Measuring fear of childbirth in the U.S.

Around the world, many studies use surveys to measure fear of childbirth. I took one of the most commonly used surveys, the Wijma Delivery Expectancy Questionnaire (WDEQ), to see if it could capture the concerns that expectant mothers in the U.S. have.

As a first step in looking at fear of childbirth in the U.S., I held a series of focus groups, involving 22 women who were pregnant or had give birth in the last five years, and asked them to take the WDEQ survey and talk about their reaction to the questions.

Since the handful of studies examining fear of childbirth in the U.S. mostly included white, well-educated women, I wanted to make sure that the focus groups were more diverse. Six of the participants identified as African-American, one as biracial, one as Middle Eastern and the remaining 14 as Caucasian.

Many of the themes that emerged in the focus group corresponded with previous research on fear of childbirth, such as fear for the baby’s health and fear of complications during the delivery.

However, women reported many other fears that had not been seen in previous research – and were not covered by the questionnaire. This is likely a reflection of the difference between maternity care systems in the United States and Scandinavian countries. It also suggests that we know very little about women’s fear of childbirth and how to address it appropriately.

Most of these fears were related to women’s interactions with health care providers, or the health system overall. Women reported fear of not having their decisions respected or fear that they would be abandoned or treated poorly by their provider. One woman said:

“I had a friend who was just alone in the bed, by herself. They took her baby away and she didn’t have any updates. That really scares me.”

Another said:

“People say ‘oh you’re a woman, you’re supposed to know what to do’ and it isn’t like that. Everything about it is terrifying and even though you may have a baby daddy or some family everyone is still looking at you and I just didn’t know; I didn’t know what to do.”

Women also alluded to larger societal constructs that affected their birth experience and contributed to their fear. For many women this was linked to the images they saw of birth in the mainstream media. As one woman said:

“You have the most intense relationship of your life with your body during pregnancy and instead of doing that in a world that honors it all we do it as a terrifying made for TV lifetime movie.”

I would like to continue this research and look at how fear of childbirth may vary by race, class and sexual orientation. I just finished another group of focus studies examining how fear of childbirth is informed by social identities. I’m also currently working on a project piloting a revised WDEQ survey that better reflects the ideas and language that women in the U.S. use to describe their fears and worries about childbirth. I hope to use this revised survey to look at the role that fear of childbirth plays in outcomes and disparities in women’s health.

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