Prevalence of fear of childbirth, its risk factors and birth outcomes in Australian multiparous women

Abstract

BACKGROUND

Fear of childbirth (FoC) is a widespread issue that impacts the health and well-being of mothers and newborns. However, there is inconsistency regarding the prevalence of FoC in the and there is limited research on the prevalence of FoC among Australian pregnant women.

AIM

To investigate the prevalence of FoC, its risk factors and birth outcomes in Australian multiparous women.

METHODS

In this prospective cohort quantitative study, 212 multiparous women were recruited from antenatal clinics at Westmead Hospital in western Sydney from 2019 to 2022. Pregnant women who attended antenatal visits and met the inclusion criteria signed the consent forms and completed several online questionnaires at baseline. After they gave birth, their birth outcomes were collected from the hospital’s medical record database. The data were analyzed using SPSS software and descriptive statistics, χ² test, independent samples t-test, and multivariable logistic regression analysis.

RESULTS

Out of 212 participants, 24% experienced a high level of FoC and 7% experienced severe FoC. The χ² test results revealed that a family income of ≤ $100000, no alcohol intake during pregnancy, pre-existing health problems, previous caesarean section (emergency or planned), and previous neutral/traumatic childbirth experiences were significantly associated with higher levels of FoC (P < 0.05). Other risk factors included being moderately to very worried and fearful about the upcoming birth, having severe to extremely severe anxiety throughout pregnancy, and expressing low relationship satisfaction. According to multivariable logistic regression, the odds of a high level of FoC were higher in women with anxiety, a history of traumatic childbirth experience, a history of sexual assault during childhood, pre-existing health problems, and lower relationship satisfaction (P < 0.05).

CONCLUSION

High-severe levels of FoC are experienced by pregnant multiparous women and are affected by several demographic factors. However, due to the small sample size in the present study, further studies with larger sample sizes are required to draw a firm conclusion on the prevalence of severe FoC among multiparous women and its associated risk factors and birth outcomes.

Key Words: Antenatal; Anxiety; Depression; Fear of childbirth; Mental health; Pregnancy; Prevalence; Stress

Core Tip: High-severe levels of fear of childbirth are common in pregnant multiparous women, are associated with several demographics and psychosocial factors and can affect birth outcomes. It is essential to develop customized maternity care and prenatal education programs in maternity facilities. To empower and support women and improve perinatal outcomes, their unique needs must be recognized, and assistance in coping with fear and anxiety must be made available in a way that contributes to a positive pregnancy experience.

INTRODUCTION

Every woman's pregnancy is a unique and personal experience[1]. Women's pregnancy and childbirth experiences can be multifaceted, meaning they may be both positive and negative at the same time. Childbirth is a defining moment in the lives of many women, but for some, the experience of childbirth can cause profound fear[2]. The fear may hover throughout the whole pregnancy, causing difficulty during labor and issues in forming future mother-newborn connections. It may even contribute to postpartum mental health problems such as anxiety and depression[3].

In a systematic review in 2018[4], the global prevalence of fear of childbirth (FoC) was reported to vary between 6.3% and 14.8%, representing Europe, Australia, Canada and the United States. Another earlier systematic review of 33 studies conducted in 18 countries demonstrated that FoC occurs in 3.7% to 43% of pregnant women[5]. A study conducted in Thailand[6] suggested a prevalence of moderate FoC of 16.1% among pregnant women, which was similar to most western studies, but identified a significantly lower prevalence in severe FoC with 0.7% prevalence compared to other western studies. The study by Zhou et al[7] also indicated a high prevalence of FoC among Chinese women, with 21% of multiparous women experiencing a moderate to severe level of fear. A more recent study among 659 English-speaking pregnant women living in Canada showed that 7.1% of them experienced FoC[8].

Variations in the prevalence of FoC could be due to several confounding factors. One of these factors is parity. According to Toohill et al[9], the prevalence of FoC in Australian nulliparous women is approximately 25%, and 14% in multiparous women. In contrast, another population-based study of FoC in women with singleton births in Finland in 1997–2010 showed that 4.5% of multiparous women and 2.5% of nulliparous women experience FoC[10]. Although the prevalence may be generally perceived to be lower in multiparous women, it is not any less significant. According to Dencker et al[11], both nulliparous and multiparous women may experience the same amount of fear; however, the causes may differ. While inexperience and a lack of education may cause fear in nulliparous women, past negative experience is considered the major contributor in multiparous women[12,13]. Studies have also suggested that while FoC in multiparous women can result from prior obstetric complications, it can also be the risk factor for untoward perinatal outcomes, such as prolonged labour and elective or emergency caesarean sections in subsequent pregnancies[12,14,15].

Evidence has shown that the prevalence of FoC in pregnant women has grown in recent years[16], including 10% in developed countries and 25% in developing countries. Also, a significant difference has been shown between the prevalence of anxiety about childbirth in Australia (30%) and in Europe (1.9%-14%)[17]. This indicates that prevalence rates are different in countries with various geographical locations. A potential reason for differences in the rate of FoC between countries could be more use of medical interventions in some locations as it can affect birth experiences and outcomes, and impact women’s fear of birth. A global study[18] using data from 154 countries between 2010 and 2018 showed a worldwide increase in caesarean section rate. Another multinational cross-sectional study, using existing data on 4729307 singleton births at ≥ 37 weeks in 2013 from 17 European countries, showed that overuse of interventions in some countries is associated with higher rate of FoC among the women[19].

For example, in European research, the prevalence of FoC was lower than that in Australia[9,12,16,20]. The reason for variability when investigating the prevalence of FoC could be methodological differences (such as using different tools to measure FoC, administration of different cut-off points for each tool, and using self-reported tools vs clinical interviews). The most common tool to measure FoC in the literature is the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), with translations into several languages worldwide[5]. However, different studies have used various cut-off points to categorize women’s level of FoC, including a cut-off score of equal to or greater than 65, 85 or 100. Fear of Birth Scale (FoBS) is another tool that has been commonly used in previous research. However, some studies have used a cut-off score of 50, while others considered a score of 54 or above to indicate a high level of FoC. Variation in the prevalence of FoC can also depend on the method of data collection. Multiple studies have assessed the prevalence of FoC using self-reported questionnaires, while others have applied diagnostic interviews using measurement of physiological indices, ensuring the women accurately indicate their FoC[4].

Multiple factors, classified as biological, psychological, cultural, and social, contribute to FoC[3]. Previous negative experiences, as well as stories of pain, suffering, and shame, may serve as risk factors for FoC[3,12]. Other risk factors identified in the research include mental health, age, education, employment, and marital status[7,9,21,22]. Nevertheless, some studies diverged in determining the effect of each risk factor, especially concerning demographics, where cultural factors may be a major contributor to FoC[9,22-24].

Timely detection and treatment of FoC is essential, as it has been shown to be associated with increased use of pharmacological pain relief during labour, delayed labour progress, higher rates of instrumental vaginal births, emergency and elective caesarean section, post-traumatic stress disorder, postpartum depression, and anxiety in subsequent pregnancies[14,20,25,26]. However, the association between FoC and poorer birth outcomes is multifaceted and can be moderated by a variety of confounding factors. For example, advanced maternal age (> 35 years), maternal overweight or obesity, pre-existing health problems, history of sexual abuse, previous emergency caesarean section, and previous 3^rd or 4^th degree tear can affect the progress of labour and birth and may result in negative birth outcomes. Thus, these factors need to be accounted for when investigating the association between FoC and birth outcomes in multiparous women[11].

To our knowledge, research on the FoC among the population of multiparous women living in Sydney, Australia, is scarce. While antenatal mental health problems have been addressed in previous research[27], previous studies primarily focused on nulliparous women, resulting in a lack of an in-depth and sophisticated understanding of this specific context among multiparous women[28]. Also, screening for mental health issues in the current healthcare system is variable and mainly covers general aspects of anxiety and depression and mainly counts on women’s self-awareness[29]. Many symptoms remain overlooked and concealed until birth[30,31]. Furthermore, labour and birth experiences and outcomes could be different in women living in Australia compared to women in other countries. For example, a recent study cross-sectional national survey of Australian women[32] showed that women wish to have less medical intervention and more freedom of choice to have a normal vaginal birth. However, an observational study of 72 low and middle income countries[33] has reported that cultural and societal perceptions around having a caesarean section as a prestigious activity have resulted in an increased rate of caesarean section births in these countries, and women report dissatisfaction with the health system if they do not achieve this goal.

Hence, we conducted this study to investigate the prevalence of FoC during pregnancy in Australian multiparous women who attended a tertiary hospital in Western Sydney. Our specific focus on multiparous women adds to the growing body of knowledge in this understudied group. In the present study, we aimed to fill the gaps in the literature by combining different measurements and using a comprehensive questionnaire that covers aspects of FoC, psychology, relationship status and female sexual function throughout the perinatal period. For a more comprehensive approach and to address the issue of measuring tools, we added the standardized FoBS to be used in conjunction with W-DEQ. We also explored factors affecting the occurrence of FoC, combining different tools and using a comprehensive questionnaire that covers aspects of FoC, psychology, relationship status and female sexual function throughout the perinatal period. Assessment of birth outcomes in women with high levels of FoC was another secondary objective of this study.

MATERIALS AND METHODS

Setting

Study participants were recruited from antenatal clinics at Westmead Hospital from 2019 to 2022.

Study design

This prospective cohort study was part of a larger mixed-methods research. Results of the comparison of FoC between nulliparous and multiparous women has been published elsewhere[34]. The authors have read the STROBE Statement, and the manuscript was prepared and revised according to the STROBE Statement.

Ethical approval

This study received full ethical approval from Western Sydney Local Health District Human Research Ethics Committee prior to its commencement (HREC Ref: 2019/ETH09781). The women signed the written consent forms before participating in the study. No identifiable data have been presented. The study adhered to the Declaration of Helsinki for the recruitment of human participants, study conduct and dissemination of results.

Sample size

The primary outcome of the study was the prevalence of FoC among multiparous women. Toohil et al[9] reported incidences of FoC of 18% (n = 801) in populations of multiparous women. The prevalence of multiparous women is roughly 60% (based on our hospital records) in the cohort attending antenatal clinic at Westmead Hospital. Thus, 212 multiparous women were required to be analyzed with 80% power and at a significance level of 0.05. The power calculation was performed using an exact test for difference in proportions of two independent samples in SPSS Advanced Statistics version 24.0.

Participants

Pregnant women were invited to participate in the study if they met the following inclusion criteria: (1) Age 18 years or older; (2) Second or third trimester of pregnancy with a singleton fetus; (3) Low-risk pregnancy; (4) Citizen or permanent resident of Australia; and (5) Multiparity.

Women were excluded from the study if they: (1) Did not speak English; and (2) Had a high-risk pregnancy or had been clinically diagnosed with perinatal mental health issues. A high-risk pregnancy can lead to increased risk of pregnancy complications accompanied by heightened stress, worries and fears. These fears and worries can mistakenly be assigned to the FoC per se. As such, we included only low risk women in our study to avoid exaggeration of the prevalence estimation of FoC among our study population. This also helped to gain better understanding of fears and emotional needs of women with low-risk pregnancies.

Outcomes of interest

Primary outcome: The primary outcome of this study was the prevalence of FoC in multiparous women.

Secondary outcome: The secondary outcomes were: (1) The association between FoC during pregnancy and sociodemographic factors, obstetric and medical history, depression, anxiety, stress, quality of relationship with the partner, sexual function; and (2) Birth outcomes including maternal outcomes (use of labour analgesia, mode of birth, perineal damage or episiotomy, postpartum hemorrhage, length of postnatal hospital stay) and neonatal outcomes [gestational age at birth, Apgar score at 5 minutes, birth weight, special care nursery or neonatal intensive unit (SCN/NICU) admission afterbirth, type of feeding at discharge].

Primary outcome measures

We used two standardized questionnaires to investigate our primary outcome, the prevalence of FoC, among the study participants, as follows. The cut-off score for each questionnaire has been selected based on the highest level of sensitivity and specificity of the tool at that cut-off point.

W-DEQ

The W-DEQ scale was used to assess FoC during pregnancy based on a woman's cognitive evaluation of childbirth[26]. This is a 33-item questionnaire with scores ranging from ‘not at all’ (0) to ‘extremely’ (5), for a minimum of 0 and a maximum of 165. A higher score indicates a higher severity of FoC. According to Ryding et al[26], a score of ≤ 37 suggests low fear, 38–65 shows moderate FoC, 66–87 indicates a high level of FoC, and a score of ≥ 85 is classified as severe FoC, with a sensitivity of 100% and specificity of 93.8%. The validity and reliability of this tool have been demonstrated in previous studies (Cronbach's α = 0.70-0.91)[9,26,35]. For the purpose of this study, we used a cut-off score of ≥ 66.

FoBS

The FoBS contains a two-item visual analogue scale that explores worry and fear about an upcoming birth by asking “How do you feel right now about the approaching birth?”[23]. Previous studies have demonstrated the tool's validity and reliability (Cronbach's α = 0.86–0.91)[36-38]. The score ranges from 0 to 100, with a higher score indicating a higher FoC[36]. In the current study, we applied a cut-off score of 50 to determine the FoC, which has been shown to have a sensitivity of 89% and specificity of 79% in previous research[36].

Secondary outcomes measures

After a comprehensive literature review, a multi-section self-reported questionnaire was designed, requesting information on the variables of interest and their association with FoC. We also used three standardized tools to investigate the participants’ mental health status, relationship satisfaction and sexual function as follows.

Depression, anxiety and stress scale

Depression, Anxiety and Stress Scale (DASS) is a collection of three self-reporting measures used to assess depression, anxiety, and stress during pregnancy. Participants were asked to use 4-point severity scales to rate the extent to which they had experienced each state over the past week. The depression, anxiety, and stress scores were derived by adding the results for the relevant items[39]. We used a cut-off score of 10 to indicate a moderate level of depression, anxiety and stress, and a cut-off of ≥ 11 to suggest a severe to extremely severe level of the abovementioned mental health problems, with a sensitivity of 86% and specificity of 64%[40]. The validity and reliability of this tool (Cronbach's α = 0.72–0.90) have been proven in previous studies[41-43].

Female sexual function index

The Female Sexual Function Index (FSFI) was used to assess female sexual function during pregnancy. This scale is a valid and reliable tool (Cronbach's α = 0.76–0.93)[44] that consists of 19 multiple-choice questions meant to gather information about women's sexual function during the previous four weeks. Six major categories of sexual function were evaluated: Desire, arousal, lubrication, orgasm, satisfaction, and pain. A Likert scale was used to grade the items. Questions 1, 2, 15, and 16 were graded on a scale of 1 to 5. The other questions included a 0 score. Domain scores were tallied to generate the FSFI total score, and a score of 26 or below indicated women with sexual dysfunction[45,46], with a sensitivity of 88% and specificity of 77%[47]. The validity and reliability of this tool were proven in previous studies[45,46].

Relationship assessment scale

The Relationship Assessment Scale (RAS) was used to measure relationship satisfaction during pregnancy. It has been identified as a valid and reliable measure (Cronbach's α = 0.86–0.91) for assessing relationship satisfaction within any form of partnered relationship by Vaughn and Baier[48] and Hendrick[49] and “is not limited to marriage relationships”[48]. It consisted of seven multiple-choice questions, with items scored on a five-point Likert scale ranging from 1 (not satisfied) to 5 (very satisfied). A mean score of 4 or higher indicated relationship satisfaction, whereas a score of less than 4 suggested relationship dissatisfaction[49].

Procedure

All pregnant women who attended antenatal clinics at Westmead Hospital were approached by the first author. They were provided with a copy of the information sheet and were explained about the purpose of the study, inclusion/exclusion criteria, right to withdraw, risks and benefits to them. They were then given sufficient time to read the information sheet and ask questions. Those who met the inclusion criteria and expressed interest in participating signed the consent form and were requested to enter a mobile number or email address on the consent form in order to receive the link to the anonymous online questions. After they signed the written consent form to participate in the study, they were given a study ID that was used to match their baseline and birth details. The participants also had the opportunity to fill in the questionnaire on the laptop provided by the researcher at the clinic. After they signed the written consent form, they were handed the laptop and filled in the online questionnaire using their study ID.

Labour and birth details for all the participants were collected from the eMaternity database. This database is routinely used to record perinatal details of all women who attend our hospital. The baseline and birth details were linked using the study IDs.

Statistical analysis

SPSS Advanced Statistics version 24.0 was used to analyze the data (SPSS, Chicago, IL, United States). After completing the online questionnaire on Survey Monkey, participants' replies were downloaded into an Excel file. Afterwards, each response choice was coded and assigned a numerical value. The complete dataset was imported into SPSS software for analysis. The sociodemographic, obstetric and medical history, mental health, sexual function, relationship data (independent variables), as well as the prevalence of FoC (dependent variable) and birth outcomes were summarized using descriptive statistics. The primary outcome, FoC, was analyzed as both a continuous variable (W-DEQ and FoBS) and a dichotomous variable.

Continuous variables were shown as mean ± SD, whereas categorical variables were shown as frequency (%) in relevant categories. The χ² test (or the Fisher exact test, where applicable) was employed to examine the relationship between FoC and independent factors. The relative risks (unadjusted confidence intervals) were calculated to explore the probability of FoC occurring in women who were moderately to very worried and fearful about the upcoming birth, had severe to extremely severe depression, anxiety and stress, and experienced sexual dysfunction and low relationship satisfaction.

Independent samples t-test was used to compare continuous non-skewed variables between women with high and low levels of FoC; these are presented as means with standard deviations. For skewed continuous data, the Mann-Whitney U test was used; these data are presented as medians with interquartile ranges.

The role of multiple factors influencing the likelihood of FoC was investigated using multivariable logistic regression analysis (backward Wald). The covariates used for multivariable logistic regression comprised of those variables that were already proven in the literature to be related to the outcome[11], including categorical demographics (age, education, country of birth, country of origin, employment, income, relationship status, social support, body mass index) and past medical and obstetric history, and also variables with a P value < 0.200 in the χ² test, such as alcohol intake, cigarette smoking, having a history of sexual assault during adulthood, mental health issues (depression, anxiety and stress) and relationship issues. A P value of less than 0.05 was considered as statistically significant.

RESULTS

A total of 212 women completed the W-DEQ and FoBS questionnaires (our primary outcome). However, only 204 women completed the DASS, and 197 answered the RAS and FSFI questions (Figure 1).

Figure 1 Flowchart of study participants. W-DEQ: Wijma Delivery Expectancy/Experience Questionnaire; FOBS: Fear of Birth Scale; DASS: Depression, Anxiety and Stress Scale; RAS: Relationship Assessment Scale; FSFI: Female Sexual Function Index; FoC: Fear of childbirth.

Prevalence of FoC

According to the W-DEQ scores, out of 212 pregnant women, 62 (29%), 85 (40%), 50 (24%) and 15 (7%) reported low, moderate, high and severe FoC, respectively (51 ± 23.4). The FoBS revealed that 89 (42%) women were moderately to very worried about the approaching birth (38 ± 28.8), and 85 (40%) had moderate to high fear about the upcoming birth (36 ± 28.5).

Risk factors of FoC

Out of 212 pregnant women who completed the W-DEQ and FoBS, only 143 completed the DASS and 139 completed the RAS and FSFI.

Results of the χ² analysis indicated that FoC was statistically significantly associated with family income ≤ $100000, no alcohol intake during their pregnancy, pre-existing health problems, previous caesarean section birth and previous traumatic childbirth experiences (P < 0.05) (Table 1 and Table 2). There were also statistically significant relationships identified between FoC and being moderately to very worried about the approaching birth, as well as having moderate to high fear of the upcoming birth, severe to extremely severe anxiety during pregnancy and lower relationship satisfaction (P < 0.05) (Table 3).

Table 1 Comparison of sociodemographic characteristics between women with low–moderate fear of childbirth and women with high–severe fear of childbirth (Wijma Delivery Expectancy/Experience Questionnaire cut-off = 66), n (%)/mean ± SD¹.

Variable	Low-moderate FoC (n = 147)	High-severe FoC (n = 65)	P value
Age			0.542
< 25	6 (4)	2 (3)
25–35	102 (69)	41 (63)
> 35	39 (27)	22 (34)
Education			0.314
No formal education	4 (3)	5 (8)
High school certificate or lower	33 (22)	14 (22)
Diploma or undergraduate degree	82 (56)	31 (48)
Postgraduate degree	28 (19)	15 (23)
Country of origin			0.092
Australia	51 (35)	15 (23)
Other	96 (65)	50 (77)
Country of birth			0.069
Australia	55 (37)	16 (25)
Other	92 (63)	49 (75)
Employment status			0.704
No formal occupation	26 (18)	17 (26)
Stopped working due to pregnancy	41 (28)	16 (25)
Casual worker	6 (4)	3 (5)
Part-time	25 (17)	9 (14)
Full-time	49 (33)	20 (31)
Marital status			0.058
Married or de facto	138 (94)	57 (88)
Divorced/separated/widow	5 (3)	2 (3)
Single	4 (3)	6 (9)
Annual family income			0.018
< $50000	35 (24)	18 (28)
$50000–100000	49 (33)	32 (49)
> $100000	63 (43)	15 (23)
Living situation			0.262
With partner	109 (74)	41 (63)
With family/friends	32 (22)	20 (32)
Alone	6 (4)	4 (6)
Support person			0.4832
Herself only	13 (9)	5 (8)
Others	134 (91)	60 (92)
Major life stressor			0.148
No	101 (69)	38 (59)
Yes	46 (31)	27 (42)
Alcohol intake			0.0692
No	134 (91)	64 (99)
Yes	13 (9)	1 (2)
Cigarette smoking			0.1572
No	133 (91)	63 (97)
Yes	14 (10)	2 (3)
History of sexual assault during childhood			0.8112
No	131 (89)	59 (91)
Yes	16 (11)	6 (9)
History of sexual assault during adulthood			0.2352
No	135 (92)	63 (97)
Yes	12 (8)	2 (3)
Age (range 22–43 years)	32 ± 4.4	33 ± 4.3	0.155
Body mass index (range 14–52)	28 ± 5.9	28 ± 5.9	0.689
Years living in Australia (range 05–43)	18 ± 12.9	17 ± 11.6	0.311

¹Percentages may not add up to 100 due to rounding.

²Fisher’s exact test.

FoC: Fear of childbirth.

Table 2 Comparison of medical and obstetric history between women with low–moderate fear of childbirth and women with high–severe fear of childbirth, n (%)/mean ± SD¹.

Variable	Low–moderate FoC (n = 147)	High–severe FoC (n = 65)	P value
Pre-pregnancy anxiety/depression			0.089
No	107 (73)	43 (66)
Anxiety only	15 (10)	8 (12)
Depression only	4 (3)	7 (11)
Both	21 (14)	7 (11)
Pre-existing health problem			0.003
No	108 (74)	34 (52)
Yes	39 (27)	31 (48)
Previous mode of birth			0.015
Normal vaginal delivery	82 (56)	32 (49)
Instrumental	30 (20)	5 (8)
Emergency caesarean section	25 (17)	19 (29)
Planned caesarean section	10 (7)	9 (14)
Previous childbirth experience			< 0.001
Neutral	46 (31)	28 (43)
Empowering	73 (50)	14 (22)
Traumatic	28 (19)	23 (35)
Previous 3rd or 4th degree tear			0.541
No	112 (76)	52 (80)
Yes	35 (24)	13 (20)
Attended antenatal educational classes			0.659
No	127 (86)	58 (89)
Yes	20 (14)	7 (11)
Type of conception			0.178
Planned	100 (68)	38 (59)
Unplanned	47 (32)	27 (42)
Gestational age at baseline (range 14–41 weeks)	30+5 ± 7+1	29 ± 7+1	0.521
Expected length of hospital stay after vaginal birth (range 0–7 days)	2 ± 1.1	2 ± 1.2	0.206
Expected length of hospital stay after caesarean section (range 0–10 days)	3 ± 1.9	3 ± 2.0	0.927

¹Percentages may not add up to 100 due to rounding.

FoC: Fear of childbirth.

Table 3 Comparison of mental health status between women with low–moderate fear of childbirth and women with high–severe fear of childbirth¹.

Variable	Low–moderate FoC	High–severe FoC	Unadjusted risk ratio (95%CI)	t value (degree of freedom)	P value
FoBS-Feeling calm about the approaching birth					< 0.001
Moderately to very calm (< 50)	100/147 (68%)	23/65 (35%)	0.40 (0.3–0.6)
Moderately to very worried (≥ 50)	47/147 (32%)	42/65 (65%)	1.5 (1.2–1.9)
mean ± SD (range 0–100)	31 ± 26.3	53 ± 28.3	22.4 (14.5–30.3)3	-5.57 (210)	< 0.001
FoBS-Feeling fear about the approaching birth					< 0.001
No or mild fear (< 50)	103/147 (70%)	24/65 (37%)	0.39 (0.23–0.6)
Moderate to high fear (≥ 50)	44/147 (30%)	41/65 (63%)	1.67 (1.3–2.0)
mean ± SD (range 0–100)	30 ± 26.8	50 ± 27.5	19.8 (11.8–27.7)3	-4.91 (210)	< 0.001
DASS-Depression					0.2432
Mild to moderate (0–10)	139/143 (97%)	57/61 (93%)	0.58 (0.3–1.2)
Severe to extremely severe (≥ 11)	4/143 (3%)	4/61 (7%)	1.42 (0.7–2.9)
mean ± SD (range 0–21)	2 ± 3.5	4 ± 4.4	1.8 (0.6–2.9)3	-3.02 (202)	0.001
DASS-Anxiety					0.005
Mild to moderate (0-10)	126/143 (88%)	44/61 (72%)	0.52 (0.3–0.8)
Severe to extremely severe (≥ 11)	17/143 (12%)	17/61 (28%)	1.48 (1.1–2.1)
mean ± SD (range 0–20)	3 ± 3.6	5 ± 4.5	1.3 (0.1–2.5)3	-2.18 (202)	0.015
DASS-Stress					0.4562
Mild to moderate (0–10)	138/143 (97%)	57/61 (93%)	0.66 (0.3–1.4)
Severe to extremely severe (≥ 11)	5/143 (4%)	4/61 (7%)	1.27 (0.7–2.3)
mean ± SD (range 0–21)	4 ± 4.1	6 ± 4.9	1.8 (0.5–3.1)3	-2.75 (202)	0.003
RAS (n = 197)					0.001
Higher relationship satisfaction (≥ 4)	122/139 (88%)	39/58 (67%)	2.18 (1.4–3.3)
Less relationship satisfaction (< 4)	17/139 (12%)	19/58 (33%)	0.62 (0.4–1.0)
mean ± SD (range 2–5)	5 ± 0.7	4 ± 0.7	0.4 (0.2–0.6)3	4.45 (195)	< 0.001
FSFI (n = 198)					0.502
Normal sexual function	25/139 (18%)	8/57 (14%)	0.81 (0.4–1.5)
Sexual dysfunction	114/139 (82%)	49/57 (86%)	1.08 (0.9–1.4)
mean ± SD (range 1–34)	17 ± 9.3	16 ± 9.3	1.9 (-1.0–4.8)3	1.35 (195)	0.089
FSFI sub-groups, mean ± SD
Desire (range 1–6)	3 ± 1.1	3 ± 1.0	0.3 (-0.1–0.6)	1.66 (195)	0.105
Arousal (range (0–6)	3 ± 2.0	3 ± 1.9	0.5 (-0.1–1.1)	1.74 (195)	0.093
Lubrication (0–6)	3 ± 2.2	3 ± 2.2	0.6 (-0.1–1.3)	1.77 (195)	0.085
Orgasm (range 0–6)	3 ± 2.4	3 ± 2.2	0.7 (-0.03–1.4)	1.92 (195)	0.061
Satisfaction (range 0–6)	3 ± 1.6	3 ± 1.7	0.02 (-0.05–0.6)	0.17 (195)	0.913
Pain (range 0–6)	2 ± 2.5	2 ± 2.3	-0.2 (-1.0–0.5)	-0.54 (195)	0.558

¹Percentages may not add up to 100 due to rounding.

²Fisher’s exact test.

³Mean difference (confidence interval).

FoBS: Fear of Birth Scale; DASS: Depression, Anxiety and Stress Scale; RAS: Relationship Assessment Scale; FSFI: Female Sexual Function Index; FoC: Fear of childbirth.

Results of the adjusted multivariable logistic regression showed that the odds of having high to severe FoC were 3.79 times greater in women with anxiety, 2.45 times higher in women who had previous traumatic childbirth experience, 5.25 times greater in women with a history of sexual assault during childhood, 2.92 times higher in women with pre-existing health problems during pregnancy, 2.92 times greater in women with pre-existing health problems and 5.28 times higher in women who reported less relationship satisfaction (Table 4).

Table 4 Multivariable logistic regression analysis comparing women with low–moderate fear of childbirth and women with high–severe fear of childbirth with respect to variables that predicted fear of childbirth.

Variable	Crude OR	Unadjusted 95%CI	Adjusted OR	Adjusted 95%CI	P value
DASS Anxiety					< 0.001
Mild to moderate (0-10)	1		1
Severe to extremely severe (≥ 11)	2.44	0.59–1.09	3.79	1.35–5.61
Previous traumatic childbirth experience					0.033
No	1		1
Yes	2.12	1.21–4.48	2.45	1.15–3.98
History of sexual assault during childhood				1.11–4.81	0.036
No	1		1
Yes	1.20	0.45–3.22	5.25	1.11–4.81
Pre-existing health problem pregnancy					0.004
No	1		1
Yes	2.53	1.37–4.64	2.92	1.40–6.12
RAS					< 0.001
Higher relationship satisfaction (≥ 4)	1		1
Less relationship satisfaction (< 4)	3.50	1.67–7.38	5.28	2.15–6.98

OR: Odds ratio; DASS: Depression, Anxiety and Stress Scale; RAS: Relationship Assessment Scale.

Birth outcomes in women with FoC

Out of 212 participants, 195 women gave birth in our hospital (17 lost to follow-up) (Figure 1). For the calculation of epidural/spinal, episiotomy and third- or fourth-degree tear, we excluded those women who had caesarean section birth.

Compared to women with low-moderate FoC, women with high-severe FoC were more likely to have neonatal admission to SCN/NICU after birth (26% vs 11%, P = 0.006). There was no statistically significant association between FoC and other birth outcomes (P > 0.05) (Table 5).

Table 5 Comparison of birth outcome in women with low–moderate fear of childbirth and women with high–severe fear of childbirth, mean ± SD/ median (25^th-75^th percentiles)¹.

Variable	Low-moderate FoC (n = 133)	High-severe FoC (n = 62)	RR (95%CI)	P value
Maternal
Epidural/spinal				0.204
No	61/94 (65%)	19/36 (53%)	0.70 (0.40–1.21)
Yes	33/94 (35%)	17/36 (47%)	1.16 (0.92–1.46)
Episiotomy3				0.576
No	80/94 (85%)	32/36 (89%)	1.29 (0.52–3.20)
Yes	14/94 (15%)	4/36 (11%)	0.92 (0.70–1.21)
Third- or fourth-degree tear3				1.000
No	92/94 (98%)	36/36 (100%)
Yes	2/94 (2%)	0
Mode of birth
Normal vaginal delivery	87 (59%)	34 (52%)	0.83 (0.55–1.24)	0.351
Instrumental	7 (5%)	2 (3%)	0.72 (0.21–2.47)	0.7252
Caesarean section	39 (27%)	26 (40%)	1.51 (1.01–2.52)	0.050
Cumulative blood loss (range 50-6500 millilitres)	300 (200–400)	300 (235–400)		0.365
Total duration of labour (range 1-26.4 hours)3	2.3 (2.3–3.6)	1.2 (0.1–3.5)		0.684
Length of postnatal hospital stay (range 4-163 hours)	45.5 (24–72)	43.5 (24–60)		0.855
Neonatal
Gestational age at birth (range 252-42.0 weeks)	38.9 ± 2.1	38.7 ± 1.5	-0.17 (-0.75-0.41)	0.559
Apgar score at 5 minutes (range 1-9)	8.8 ± 0.9	8.9 ± 0.5	0.09 (-0.16–0.34)	0.467
Birth weight (range 800-4685 g)	3291.2 ± 550.9	3333.3 ± 614.5	42.04 (-131.4-215.5)	0.633
Resuscitation after birth				0.716
No	106 (80%)	48 (77%)	0.91 (0.56–1.48)
Yes	27 (20%)	14 (23%)	1.05 (0.82–1.34)
SCN/NICU admission after birth				0.006
No	119 (90%)	46 (74%)	0.52 (0.35–0.79)
Yes	14 (11%)	16 (27%)	1.55 (1.04–2.29)
Received infant formula during hospital stay				0.273
No	87/123 (71%)	35/56 (63%)	0.78 (0.50–1.21)
Yes	36/123 (29%)	21/56 (38%)	1.13 (0.90–1.42)

¹Percentages may not add up to 100 due to rounding.

²Fisher’s exact test.

³Excluding caesarean section births.

RR: Relative risk; SCN: Special care nursery; NICU: Neonatal intensive unit; FoC: Fear of childbirth.

DISCUSSION

Prevalence of FoC

Our study aimed to investigate the prevalence and risk factors of FoC among pregnant Australian multiparous women. We discovered that 24% of individuals had a high FoC. This conclusion is consistent with other findings in the literature, which revealed a prevalence of high FoC ranging from 3.2% to 43%[5]. The prevalence of severe FoC (7%) in our study was similarly comparable with the findings of a Finnish study, in which the measured prevalence for severe FoC using W-DEQ was 7.7%[16]. Despite these findings, the prevalence of severe FoC in our research was greater than in a recent Australian study, where 3.6% of multiparous women who answered the questions on W-DEQ experienced severe FoC[9]. In the Finnish study[16], the participants were recruited regardless of their gestational age, parity or the reason for visiting the maternity outpatient clinics. As such, all nulliparous, primiparous and multiparous women were included in that study. Also, most women at 12-19 weeks of gestation attended the clinic for their routine ultrasound visits. In the Australian study[9], the majority of participants were in their second trimester of pregnancy (11–25 weeks), 74% of the participants were born in Australia (compared to one-third in our study), and the study sample included both nulliparous and multiparous women, which could have affected the overall reported rate of FoC.

Another potential explanation for such a large discrepancy might be the coincidence of our data-collecting period with the onset of the coronavirus disease 2019 (COVID-19) epidemic. According to recent research, women were at a higher risk of developing mental health disorders during the pandemic, which may have led to a higher prevalence of severe FoC[50,51]. Another rationale for contradictions within the literature is the use of different research methodologies or data collection tools across studies, as explained earlier. Further to these, fear is not a stable notion and can be influenced by a variety of confounding circumstances, such as previous childbirth experiences and cultural factors[22]. Earlier research has also revealed a link between an increase in women's anxiety as they approach their due dates, which may contribute to a greater level of FoC in the third trimester compared to previous trimesters[9,41,52]. Nonetheless, because most perinatal mental health research has been cross-sectional, and there is a dearth of longitudinal studies to demonstrate a causal association, the relationship between pregnancy progression and increased FoC has not been proven in the literature[22]. To close this knowledge gap, further long-term research is essential.

Risk factors of FoC

FoC is related to various risk factors such as women’s personal, internal and external conditions[11]. Our study revealed that FoC was statistically significantly associated with anxiety, previous traumatic childbirth experiences, history of sexual assault during childhood, pre-existing health problems and relationship dissatisfaction with the partner. Earlier literature has indicated that demographic factors may escalate childbirth-related stress and affect women’s anticipation or experience of the birth process. For example, a population-based study in Norway[53] showed that poor social support and a previous negative birth experience strongly impacted the participants’ FoC. Also, according to a systematic review in 2021[54], there is a link between child sexual abuse, anxiety disorders and traumatic childbirth with an increased likelihood of medical interventions during labour and birth. While there is variation in the rate of child sexual abuse between countries ranging from 2% to 53%, pregnant women with a history of childhood sexual abuse show different behaviors. For example, they are more likely to drink alcohol during pregnancy, have eating disorders, preterm birth and an infant with low birth weight and developmental issues[54].

Our finding on previous negative/traumatic birth experiences corroborates those of Hall et al[55] and Toohill et al[9], who found that FoC was associated with past negative birth experiences. Negative birth experiences may lead to subsequent mental health problems, such as post-traumatic stress disorder and persistent FoC[56]. A study by Nilsson et al[14] showed that the prevalence of FoC after one year in women with a ‘less than positive’ birth experience was 61% compared to 12% in women with a positive birth experience (relative risk = 5.1). In our study, we also observed that having a neutral previous childbirth experience did not help reduce FoC since 43% of the individuals in our study who felt neutral about their previous experiences had high–severe FoC, compared to 31% of those who had low–moderate FoC. While a positive birth experience is critical for tranquil subsequent pregnancies, one-fifth (22%) of the women with high-severe FoC in our study had prior empowering childbirth experience.

Although our study did not find a statistically significant association between FoC and the participant’s country of birth or country of origin, it is noteworthy to mention that most women attending our hospital are from culturally and linguistically diverse backgrounds. Some of them have already had the experience of giving birth in other countries with different perinatal care systems compared to Australia. This could have contributed to their high–severe level of FoC despite having a previous positive birth experience. However, there is conflicting evidence in the literature about the relationship between these risk factors and FoC. The discrepancy may be explained by differences in socio-cultural-demographic factors among studies, particularly on an international scale. Personal beliefs about perceiving childbirth as a risky medical occasion, cultural attitudes for or against normal vaginal birth, prior negative experience of busy or unhygienic birthing rooms, and fear of insufficient support from medical staff all contribute to FoC in different studies[5].

Several aspects of mental health have been linked to FoC. The current study established a relationship between severe to extremely severe anxiety and an elevated risk of FoC. This finding is consistent with the reports by Nordeng et al[1], who proposed a link between FoC and anxiety. Also, the study by Størksen et al[53], using the WEDQ cut-off point of 85, showed a strong association between impaired mental health and FoC. Contrasting with prior literature, we did not identify a statistically significant relationship between FoC, depression, and stress using the DASS tool[1,2,7]. This could have been due to the use of different research methodologies or different tools to investigate women’s mental health. We used self-reported DASS-21 to estimate women’s depression, anxiety and stress. In contrast, Størksen et al[53] used Edinburgh Postnatal Depression Scale to screen for symptoms of depression and the Hopkins Symptom Checklist to investigate participants’ symptoms of anxiety.

Birth outcomes and FoC

Although we showed that women with higher levels of FoC had more unfavorable birth outcomes, such as higher rates of CS and neonatal admission to SCN/NICU, the differences were not statistically significant. This might have been due to the 8% lost-to-follow-up and availability of birth outcomes for only 195 women out of 212 participants, affecting the study power for birth outcomes. Therefore, further exploration is needed to determine the clinical significance of these findings. Nevertheless, in real practice, clinicians may be guided by more than just the P value. They need to exercise their clinical judgment based on the possibility of unfavorable outcomes in these women, such as the progress of labour.

The lower rates of tears, episiotomy and epidural/spinal use during a vaginal birth in women with high levels of FoC may be justified by the greater rate of caesarean section in these women compared to those with low-moderate levels of FoC. Furthermore, shorter lengths of postnatal hospital stay in women with higher levels of FoC could have been due to the impact of the COVID-19 pandemic, causing fear of prolonged hospital stays and consequent contraction of the virus.

Strengths and limitations

While previous research on FoC has predominately focused on nulliparous women, our specific focus on multiparous women contributes to the expanding body of knowledge in this underexplored population. The use of comprehensive online questionnaires that examined several facets of FoC is one of the present study's strengths. In several earlier studies, W-DEQ was employed as the only well-used and well-validated measuring instrument for FoC. In comparison, we adopted W-DEQ as our primary instrument for assessing the prevalence of FoC, with FoBS serving as a supporting and confirmatory measure. Furthermore, our study cohort was ethnically diverse compared to earlier studies, allowing us to investigate novel demographic risk factors associated with FoC. In addition, parity is a crucial predictor of FoC, and we eliminated nulliparous women from our study to exclude the influence of being a first-time mother on the prevalence of FoC among our participants.

Nonetheless, there are several limits to our research. In order to assess relationship satisfaction and sexual dysfunction during pregnancy, the RAS and FSFI tools were added to the questionnaires. These questions, however, were not completed by all women. Despite the fact that it was a self-reported anonymous online survey, some participants were hesitant to complete the questions on relationships and sexual function for cultural reasons, as well as the time (20–25 minutes) necessary to complete the entire survey. Self-report questionnaires might have also led to inflated prevalence. Furthermore, the obstetric and postnatal results could not be investigated due to the disruptive impact of COVID-19 on the study schedule. Although we excluded high-risk women in our study to have purer results, future studies are recommended to compare the FoC between women with low-risk and high-risk pregnancies.

Our study was conducted in a public hospital in western Sydney and did not include data from private hospitals or other public hospitals across the state of New South Wales or Australia. Future research may examine the prevalence of FoC among women in both public and private settings. Additionally, in current study, we did not recruit participants from multiple locations, therefore, our study sample was not representative of Australian population. We excluded women with high-risk pregnancies or women diagnosed with mental health concerns such as depression or anxiety, and we did not compare our sample characteristics to the characteristics of the population of birthing women in our hospital. As such, our findings may not be generalized to the population of birthing people in Australia.

Recommendation for practice

The current study provides essential evidence for the development of prenatal education program in maternity facilities. With the calculated prevalence of FoC in Australian multiparous women in this study, hospitals can be better equipped to provide customized maternity care. It is crucial for healthcare providers to understand women's pregnancy journeys, particularly for multiparous women who have had negative or traumatic childbirth experiences. To empower and support women through these program, their unique needs must be recognized, and assistance in coping with fear and anxiety must be made available in a way that contributes to a positive pregnancy experience and birth outcome[57].

Previous studies in Western countries have shown that the majority of maternity clinics do not provide special services or counselling support for FoC[58]. This highlights the need to develop standardized pathways of care and interventions for women with FoC. Also, risk factors of FoC, including women’s socio-cultural background, general health, psychological status, level of support and prior birth experience, need to be taken into consideration by clinicians when providing antenatal care to women. In addition, women who request antepartum interventions, such as epidural or caesarean section with no medical reason, should be consulted to explore their mental health status and level of FoC and be provided timely support. Furthermore, women with high-severe FoC may benefit from continuous midwifery care throughout pregnancy and labour as the stability and familiarity of a relationship with the midwife can help enhance their experience of childbirth[57].

While pregnancy and childbirth are unique experiences for women, those with a history of childhood sexual abuse may experience more challenges during this life-changing period. The association between childhood sexual abuse and negative maternal and neonatal outcomes necessitates the need for accurate assessment and screening to detect those who are at risk and provide them with trauma-sensitive care and consideration[54].

Future research directions

It is recommended to conduct a longitudinal study to observe the changes in FoC with pregnancy progression and its long-term impact on the perinatal outcomes after birth. Future studies also need to compare the FoC levels between low-risk and high-risk pregnant women, and explore the unique needs and intervention strategies of different risk groups. In addition, further studies are required to explore the differences in the incidence of FoC between public and private healthcare environments, and understand the impact of different healthcare systems on women's childbirth experience.

CONCLUSION

Using the W-DEQ, we discovered that 24% of Australian multiparous women experienced high FoC, and 7% experienced severe FoC. We discovered that a ≤ $100000 family income, no alcohol intake, pre-existing health problems, previous caesarean section, past neutral/traumatic childbirth experience, and severe to extremely severe anxiety were all related to worsened FoC. Furthermore, women who had anxiety, experiences of previous traumatic childbirth, a history of childhood sexual abuse, pre-existing health problems during pregnancy, and poorer relationship satisfaction had greater likelihood of experiencing FoC during pregnancy. Women with high levels of FoC were more likely to have neonatal admission to SCN/NICU after birth. However, due to the small sample size in the present study, further studies with larger sample sizes are required to draw a strong conclusion on the prevalence of severe FoC among multiparous women, and its associated risk factors and birth outcomes.

ACKNOWLEDGEMENTS

We appreciate the in-kind support we received from the Department of Women’s and Newborn Health at Westmead hospital to conduct this study. We would like to thank the managers and clinicians at the antenatal clinic at Westmead hospital for their valuable cooperation and support during data collection stage.