Caesareans due to birth fears

“Women who opt for caesarean aren’t too posh to push – just scared,” reads a Daily Mail headline today. It is one of several news articles on research that found that almost half of expectant mothers who decide to have a caesarean for non-medical reasons, do so because they are afraid of a natural delivery.

The Daily Telegraph says that the most vulnerable are first time mothers who had heard “horror stories” from friends and relatives and those who were unhappy and looking forward to motherhood less.

The findings are from a study of the attitudes towards birth of around 500 pregnant Swedish women. Some degree of fear or apprehension about giving birth is common in many first time expectant mothers. This study highlights the need for pregnant women to have the opportunity to talk through their concerns with healthcare professionals. There are many benefits to having a natural delivery, including a faster recovery time and not being exposed to the risks that are inherent with surgical procedures. The majority of caesareans in the UK continue to be performed for medical reasons related to the mother, baby or pregnancy, rather than as a personal birth choice.

Nice (National Institute of Clinical Excellence) guidelines recommend that women who request a caesarean because of a fear of childbirth are offered counselling (such as cognitive behavioural therapy) to help them to address their fears, as this results in reduced fear of pain in labour and therefore shorter labour.

Where did the story come from?

Dr Ingela Wiklund and colleagues from Danderyd Hospital and the Karolinska Institute, Sweden carried out the research. The study was supported by the County Council of Stockholm and a maternity hospital in Stockholm. The study was published in the (peer-reviewed): British Journal of Obstetrics and Gynaecology.

What kind of scientific study was this?

In this cohort study, the authors looked at the expectations and experiences of three different groups of pregnant women: those having a caesarean from personal choice; those having a caesarean due to breech birth; and those women having a natural delivery.

Between January 2003 and June 2005, the researchers recruited 496 healthy first-time mothers who had reached full term in their pregnancy. The three groups included 104 women having a caesarean by their own request, 128 women having a caesarean due to a breech baby and 264 women planning a vaginal birth. The women who had requested a caesarean received one hour of counselling from an experienced doctor about the advantages and disadvantages of natural and caesarean births.

All the women completed two questionnaires; the first on their expectations leading up to the birth and the second three months later on their experiences of giving birth. Both used recognised scales to measure the women’s degree of fear or negative experiences. The pre-birth questionnaire included an assessment of the degree of anticipation of becoming a mother; concerns about losing personal control during labour; and concerns about injury to the baby.

The women planning a natural delivery were separately assessed after birth depending on whether the delivery went ahead without problems, whether they had to have an assisted delivery (e.g. forceps) or whether they had to have an emergency caesarean.

The study excluded obese women or those with complications during pregnancy.

What were the results of the study?

Of the 496 women recruited, the researchers got back both completed questionnaires from only 47% of the maternal request caesarean group, 54% of the breech caesarean group, and 48% of the natural delivery group.

They found that women who requested caesarean delivery were generally non-Swedish, slightly older, and were less likely to have participated in parenthood education classes. Between groups, there was a significant difference in the degree of negative expectation about delivery, with women requesting caesarean having the highest total score.

Of the request group, 43.4% had a score signifying they had a significant fear of childbirth, compared to 13.2% of the vaginal group and 6% of the breech group. A larger proportion of the request group also attained higher scores that indicated severe fear. Further analysis revealed that the women requesting caesarean scored higher than the other groups on measures of feeling less happy at time of assessment and of having fear that the baby would die.

At the three month assessment, the researchers found that mothers who were planning a natural birth, but who had to have an emergency assisted or caesarean delivery had more negative experiences of birth. However, there was no relationship between the expectations and the experiences of the mothers who requested caesarean.

What interpretations did the researchers draw from these results?

The researchers conclude from their results, “many but not all women requesting a caesarean section suffer from childbirth fear”. The finding that women who had planned for a vaginal delivery, but subsequently experienced complications had more negative birth experiences also highlights the need for postnatal support.

What does the NHS Knowledge Service make of this study?

Some degree of fear or apprehension about giving birth will be common in many first time expectant mothers. This study highlights the need for pregnant women to have the opportunity to talk through any concerns that they have about the birth with healthcare professionals. However, it should be acknowledged that:

• These findings are based on the study of only a very small number of women and a large proportion of these women failed to complete the questionnaires. It is therefore debatable how representative the women who answered the questionnaire are of women in general.
• At the time they answered the pre-birth questionnaire, all the women who had requested a caesarean knew by this point that they were not going to have to experience a natural delivery. Therefore, their responses about fear of childbirth may differ considerably from any that they would have given earlier in the pregnancy when a natural delivery was expected.
• The study was conducted in Sweden where obstetric care and experiences may not be directly transferable to women in other countries.
• Only first-time mothers with no previous experience of birth were examined by this study. It would be interesting to see whether expectations and experiences differed in women who had previously had children.

There are many benefits to having a natural delivery including faster recovery time and avoiding the risks that are inherent with surgical procedures. The majority of caesareans in the UK continue to be performed for medical reasons related to the mother, baby or pregnancy, rather than as a personal birth choice.

Sir Muir Gray adds...

The prevention and management of fear is one of the main skills of the midwife.