Fear factor
Impending childbirth is a scary prospect, even for women
who have already "been there, done that". Psychologist Dr Melanie
Woodfield discusses how you can prepare yourself emotionally for
labour, and cope with your fear.
We all spend time preparing practically for birth - poring over
lists of recommendations of what to take to hospital, packing bags,
and later unpacking all of the items we were sure would be useful
but never made it out of the suitcase! But how much time do we
spend preparing mentally and emotionally? For many women, this
emotional preparation will involve coping with a degree of fear
about the impending labour.
While most women eagerly await the birth
of their child, fear of childbirth is very common. In fact, in a
2007 survey of 300 pregnant women in Hong Kong by Tsui and
colleagues, all of the surveyed women reported some degree of fear,
and 22% of the women had considered requesting an elective
caesarean due to the extent of their fear of labour!
Fear can also influence pain relief
choices - a study by Heinze and Sleigh in 2003 found that women who
chose to deliver with epidural pain relief tended to have a
high-level of fear of childbirth.
In extreme cases, this profound fear of
childbirth (often despite desperately wanting a baby) is known as
tokophobia. This condition, while first formally described by
Kristina Hofberg and Ian Brockington in 2000, is not new. Various
authors have written both helpful and unhelpful comments about
childbirth fear for many years - consider Jones' 1942 comment: "In
labour, the woman's true character is revealed. If it is harmonious
and loving, all goes well. If it contains conflicting elements of
hate, resentment, envy, and fear, then they reflect themselves in
disturbances of the labour process."
Various studies have examined exactly
what pregnant women are afraid of, and the origins of these fears
are not surprising. In Tsui's 2007 study, women identified that a
powerful contributor to their fear of childbirth was "negative
stories". Have you ever noticed that movies and television often
portray labour as intensely loud, sweaty, long, and very painful?
And the stories we hear circulating when mothers get together are
usually horror stories of difficult births. We don't often hear
stories of straightforward and easy births, despite many such
births occurring every day! Also, those negative stories tend to
stick in our minds more readily.
In 2006, Colleen Fisher and her colleagues
carried out in-depth interviews with 22 Australian women to
investigate themes of women's fear of childbirth. They agreed that
"horror stories" were an important contributor to fear, and also
identified factors such as fear of the unknown, fear for the
wellbeing of the baby, fear of pain, losing control and
disempowerment, and the uniqueness (and unpredictability) of each
birth.
For women who had given birth previously,
"previous horror birth" and "speed of birth" were the two factors
most strongly contributing to fear of future deliveries. In a large
study of more than 8,000 pregnant women, by Geissbuehler and
Eberhard in Switzerland, fear for the child's health and fear of
pain were the most frequently mentioned concerns. Carola Eriksson
and her colleagues surveyed 410 women in Sweden in 2005 and found
that "exposedness and inferiority" was the key factor contributing
to women's fear of childbirth, suggesting possible slight cultural
differences in exactly what contributes to fear.
In Colleen Fisher and her
colleagues' study, two central factors emerged as helping to reduce
fear of childbirth: Positive relationships with midwives, and
the support women receive from their social network. education,
such as attending antenatal classes, can also help to reduce
anxiety.
An intervention that has been
shown time and time again to assist with fear (and anxiety in
general) is Cognitive Behavioural Therapy, also known as CBT. In a
nutshell, CBT proposes that how we think and feel about an event,
such as labour, has a significant effect on how we experience that
event. Psychologists like Aaron Beck have devoted their careers to
studying the relationships between our thoughts, feelings, and
behaviour, and have concluded that these factors are powerfully
interrelated. Beck proposed a "five-part model" to understand this
relationship:
• Thoughts. Both what is running through our
mind at the time ("automatic thoughts") and the deeper beliefs
("core beliefs") that drive our thinking patterns. Examples:
"I can't do this, it hurts too much!" or "I am a strong, powerful
woman."
• Emotions. How we feel, which can vary widely
from moment to moment. Examples: worried, angry, excited,
scared.
• Physiology. The processes that occur within
our bodies. Examples: increased heart rate, blood pressure,
sweating, breathing rapidly.
• Behaviour. What we do. Examples: Shouting,
sitting, lying down, walking, talking. Some psychologists even
assert that thinking is a behaviour!
• Environment. The characteristics of the
surroundings we're in. Not only the physical aspects, but the
social and emotional aspects too. Examples: Living room vs hospital
room, partner present vs partner absent, busy vs quiet, partner
anxious vs partner calm.
If we're thinking and feeling a certain
way, this can lead to us doing certain things, which changes what's
happening in our bodies and how we interact with our environment.
Consider the following example:
Sarah, a first-time mum, is in early
labour. Sarah's mother has repeatedly told her how painful labour
is and Sarah has been dreading labour since before she became
pregnant. She thinks that she won't be able to cope (thought) and
is petrified (emotion) that she will pass out and possibly die.
Sarah finds herself panicking when she feels the first
contractions. She starts to hyperventilate (body) and feels faint.
Sarah tells herself that this means that her worst fear is
beginning to come true and stands up (behaviour), breathing
rapidly. Her partner, worried for Sarah, is talking very quickly,
trying to calm her, and demanding, "Are you okay?" loudly and
repeatedly (environment). Sarah faints. Her worst fears are
realised, and, when she is revived, her LMC assesses that the
baby is in distress and Sarah requires an emergency
Caesarean.
How we think and feel about a
situation can start, or contribute to, a chain of events that can
have unwanted consequences. The good news is that changing one
aspect (usually how we think) can have a profound effect on the
other factors. Consider this alternative scenario:
When Sarah feels the
first contractions, she feels a flash of panic and thinks, "Oh no,
this is it!" She feels the old familiar thoughts come rushing in,
but instead of allowing them to overwhelm her, she concentrates on
breathing slowly, and asks her partner to bring her a document she
had spent a lot of time thinking about and preparing. She slowly
and carefully reads this paper repeatedly over the next few hours,
and her partner and LMC calmly remind her of the statements written
there. Sarah feels the pain of labour, but she doesn't feel
overwhelmed.
While it seems like all Sarah was
doing in the second scenario was "thinking positively", challenging
unhelpful thoughts with balanced or adaptive thoughts is more than
simply thinking positively. Adaptive thoughts are honest and
truthful, but balanced. For example:
• Negative thought: "This is the most painful thing I've ever
felt."
• Thinking positively: "I feel great - can't feel a
thing."
• Balanced thinking: "This hurts, but it is temporary,
and I am strong." 
Spending time carefully preparing a
document with coping statements or adaptive thoughts, as Sarah did
in the second example, can pay huge dividends in reduced anxiety
during labour. These statements will be different for every
woman, and may include Bible verses, affirmations, poetry, or
pieces of advice that have meaning. For example:
• The average length of first labour is 12-14 hours, so
no matter how painful it is, it will be over soon.
• Every contraction is another step closer to the end.
• I am young, big, strong, and built for this.
• As much as it hurts, it is normal, familiar, useful
pain, which will not kill me or the baby.
• As contractions get more intense, they're getting more
efficient.
• 60,470 babies were born in new Zealand in the year ending
March 2007 (approximately 166 per day), and among all those women,
there were bound to be people more scared/in pain/more panicked
than me, and they did it!
• Many women have more than one baby, so it can't be too bad
if they choose to go through it again.
It is very important to expect that your
carefully considered adaptive thoughts and coping statements will
be challenged! For most women, labour is a physically and
emotionally demanding time. Also, factors outside of your control,
such as the need for medical intervention, can be
unexpected and frightening.
Again, coping with these events is likely
to be enhanced by good preparation, such as learning about common
medical procedures from classes, books, or the internet.
Incorporate the possibility of a "plan B" birth into your thinking
- the old adage of hoping for the best but preparing for the
worst.
In some cases, particularly following
difficult births, an anxiety disorder develops in between 1-3% of
women. Known as Post-traumatic Stress Disorder (PTSD), symptoms
include distressing memories, flashbacks, avoidance of cues or
reminders of childbirth, nightmares, irritability and sleeping
difficulties. According to a study by Johan Soderquist and his
colleagues, factors that increase the likelihood of PTSD developing
include depression during pregnancy, severe fear of childbirth,
extreme stress during pregnancy, and previous mental health issues.
If you are concerned about possible PTSD, talk to your LMC
or GP who can put you in touch with your local maternal mental
health service.
Dr Melanie Woodfield is a child and adolescent clinical
psychologist in Auckland.
References
• Eriksson, Carola,;Westman, Goran; and
Hamberg, Katarina. "Experiential factors associated with
childbirth-related fear in Swedish women and men: a
population-based study." Journal of Psychosomatic Obstetrics &
Gynaecology 26.1 (Mar 2005): 63-72.
• Fisher, Colleen; Hauck, Yvonne; and Fenwick, Jenny.
"How social context impacts on women's fears of childbirth: a
Western Australian example." Social Science & Medicine 63.1
(Jul 2006): 64-75.
• Geissbuehler, V and Eberhard, J. "Fear of childbirth
during pregnancy: a study of more than 8000 pregnant women."
Journal of Psychosomatic Obstetrics & Gynaecology 23.4 (Dec
2002): 229-35.
• Heinze, SD and Sleigh, Mary J. "Epidural or no
epidural anaesthesia: relationships between beliefs about
childbirth and pain control choices." Journal of Reproductive and
Infant Psychology 21.4 (nov 2003): 323-33.
• Hofberg, Kristina and Brockington, Ian. "Tokophobia:
an unreasoning dread of childbirth. a series of 26 cases." British
Journal of Psychiatry 176 (Jan 2000): 83-85.
• Soderquist, Johan; Wijma, Barbro; and Wijma, Klaas.
"The longitudinal course of post-traumatic stress after
childbirth." Journal of Psychosomatic Obstetrics & Gynaecology
27.2 (Jun 2006): 113-19.
• Tsui, Michelle H; Pang, Man W; Melender, Hanna-Leena;
Xu, L; Lau, Tze K; and Leung, Tse n. "Maternal fear associated
with pregnancy and childbirth in Hong Kong chinese women." Women
& Health 44.4 (2007): 79-92.
As seen in OHbaby! magazine
Issue 4: 2009
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