Un- 5

Prenatal fear of childbirth and anxiety sensitivity

KERRY SPICE1,2, SHANNON L. JONES2, HEATHER D. HADJISTAVROPOULOS2,

KRISTINE KOWALYK3, & SHERRY H. STEWART4

1Faculty of Education, Research & Graduate Programs, University of Regina, Regina, SK, Canada, 2Department of

Psychology, University of Regina, Regina, SK, Canada, 3Functional Rehabilitation & Extended Care Programs KRISTY,

Regina Qu’Appelle Health Region, Regina, SK, Canada, and 4Departments of Psychiatry and Psychology, Dalhousie

University, Halifax, Canada

(Received 1 July 2008; revised 23 March 2009; accepted 30 March 2008)

Abstract Objective. Fear of childbirth (FOC) or what is historically referred to as tokophobia (a phobic state where a woman avoids childbirth despite desperately wanting a baby), is known to complicate the delivery process. In this study, the relationship of Anxiety Sensitivity (AS) to FOC was examined given that AS is a risk factor for other fears. Specifically, the contribution of three AS dimensions (physical, psychological or social concerns) relative to other factors (e.g., parity of the mother, trait anxiety) in accounting for FOC was explored. Methods. Women in their final 4 months of pregnancy (n¼ 110) completed the Anxiety Sensitivity Index, the State-Trait Anxiety Inventory-Trait Scale and the Wijma Delivery Expectancy/Experience Questionnaire. Results. Most demographic variables were non-significant in predicting FOC with the exception of participants’ parity. Multiple regression analysis revealed that AS-physical concerns significantly predicted elevated FOC even after controlling for parity and trait anxiety; higher levels of AS-physical concerns, higher trait anxiety, and expecting a first child all independently predicted greater FOC. Conclusion. Variance in FOC is explained, in part, by AS-physical concerns. Further, AS-physical concerns are distinct from trait anxiety in predicting FOC. Similar to other fears, the results support the possibility that AS may be a risk factor for elevated FOC.

Keywords: Fear of childbirth, tokophobia, anxiety sensitivity, trait anxiety, pregnancy, parity, pregnancy complications

Introduction

Fear of childbirth (FOC) is conceptualised along a

continuum, with women who are almost free of fear at

one end, and those women with severe or disabling

fear at the other [1]. Roughly 33% of women admit to

being fearful of childbirth [2], with anxiety peaking

during the last trimester [3]. Between 11 and 14% of

women present with severe FOC [4,5] that can be

highly disabling [6]. Some women avoid becoming

pregnant, others opt for abortion, and still others

request an elective caesarean section (CS) or undergo

emergency CSs because of severe FOC [5]. The

positive relationship between FOC and CSs is an

important one. Although the rates of maternal death

are no different for Canadian women undergoing

planned vaginal delivery versus planned CS, the risks

of severe maternal morbidity (e.g., postpartum risks of

cardiac arrest) remain significantly higher for women

who undergo a planned CS [7].

Beyond the increased risk of CSs among women

with elevated fear, there are other reasons to attend to

FOC. For instance, FOC is associated with increased

fear during labour [8], which subsequently leads to an

increased need for pain relief during labour [9].

Likewise, women with elevated fear who do not

undergo counselling appraise the birth experience

more negatively than those who seek guidance from a

midwife [10]. Women with FOC who have a negative

birth experience have been found to suffer from post-

natal depression, symptoms of PTSD, and delayed

bonding with their infant [11]. Theoretically, alleviat-

ing severe FOC can assist women with achieving

greater satisfaction during pregnancy and childbirth.

Indeed, researchers have found that women with

severe FOC who initially desired an elective CS

Correspondence: Heather D. Hadjistavropoulos, Department of Psychology, University of Regina, Regina, Saskatchewan S4S0A2, Canada.

Tel: þ306-585-5133. Fax: þ306-337-3227. E-mail: [email protected]

Journal of Psychosomatic Obstetrics & Gynecology, September 2009; 30(3): 168–174

ISSN 0167-482X print/ISSN 1743-8942 online � 2009 Informa UK Ltd.

DOI: 10.1080/01674820902950538

benefited from individualised psychological and ob-

stetrical support, with 40% subsequently able to

undergo vaginal delivery [12].

Predictors of fear of childbirth

Predictors of FOC are manifold. FOC differs among

women who have previously given birth (parous)

when compared with women who are expecting their

first child (nulliparous). Specifically, nulliparous

women report higher levels of FOC on average than

parous women [1,9], which may be because of a lack

of experience with childbirth [9]. Interestingly, the

relationship between maternal parity and FOC is

slightly different when we examine categories of FOC

severity (e.g., moderate, severe). Moderate FOC

appears to be more common among nulliparous

women; however, severe FOC and a request for CSs

appears more common among parous women [13].

Moreover, severe FOC in parous women has been

associated with earlier traumatic delivery experi-

ences, such as an emergency CS [14] or vacuum

extraction [15].

Personality may also predict FOC in pregnant

women. Specifically, trait anxiety or the relatively

stable disposition to be anxious [16], has been linked

to FOC [1,4]. Consequently, moderate to extreme

FOC has been related to a number of anxiety

disorders and phobias, including PTSD, blood

phobia, animal phobia and agoraphobia without a

history of panic disorder [5].

Beyond these two fundamental variables of pre-

vious childbirth and trait anxiety, specific character-

istics such as fear of pain and low pain tolerance have

been cited as common reasons for FOC [17]. Lack of

social support or expressed dissatisfaction with one’s

partner is also predictive of FOC [18]. Other women

fear the negative physical consequences of childbirth,

such as a fear of rupturing [15,19] and fear of injury

to themselves [19] or to the unborn child [20]. Yet

others cite fear of death [19,20], fears of the

unknown, fear of losing control or fear of appearing

silly during the delivery as reasons for FOC [17].

Anxiety sensitivity and fear of childbirth

To date, the relationship between anxiety sensitivity

(AS) and FOC has not been examined. AS is the fear

of anxiety-related bodily sensations (e.g., heart

palpitations, dizziness) that result from beliefs that

these sensations or anxiety experiences have harmful

somatic, psychological or social consequences [21].

The expectancy model of fear maintains that there

are three fundamental fears (or fears of stimuli that

are inherently aversive) that include fear of injury,

fear of negative evaluation and fear of anxiety [21].

This model predicts that holding such fundamental

fears may predispose individuals to other common

fears. Of the three fundamental fears, fear of anxiety

(or AS) has received the most attention by research-

ers. It is thought that high AS people acquire

common fears (e.g., of spiders, flying) more readily

than others because exposure to such commonly-

feared objects and situations may be expected to lead

to the anxiety-related sensations high AS people find

so aversive.

To date, research on this aspect of the expectancy

model has been supported. For instance, severity of

AS has been correlated with the intensity and

number of fears that a person holds [22,23]. More-

over, AS has been found to play an important role in

panic attacks [24], panic disorder [25] and PTSD

[26]. Such findings are consistent with the position

that AS is a risk factor for the development of fear,

anxiety and panic.

Factor analytic research on the most widely used

measure of AS, the Anxiety Sensitivity Index [22],

has established that AS is both a hierarchical and

multidimensional construct consisting of a higher-

order factor (global AS), and three lower-order AS

factors of physical, psychological and social concerns

[27]. AS-physical concerns refer to the fear of

somatic symptoms because of the belief that these

symptoms are indicative of physical illness. AS-

psychological concerns refer to fears of cognitive

dyscontrol because of the belief that these symptoms

are indicative of mental illness whereas AS-social

concerns refer to fears of publicly observable anxiety

reactions because of the belief that display of anxiety

may result in public embarrassment or social rejec-

tion [28].

It seems important to examine AS and its relation-

ship to FOC for several reasons. First, AS is

associated with high levels of pain during labour,

including both sensory and affective components of

pain [29], and AS has been shown to exacerbate

avoidance of pain-related activities [30]. Moreover,

AS has been found to prime fear reactivity to bodily

sensations [31], and may predict subjective distress

and reported symptoms in response to procedures

that induce strong physical sensations [32]. In the

context of pregnancy, women with high AS may

perceive natural childbirth and associated procedures

as a painful activity fraught with unpleasant bodily

sensations. Consequently, pregnant women with

high AS may engage in pain-avoidance activity and

reject vaginal birth. Instead, they may seek CSs

unnecessarily by scheduling an elective CS or by

undergoing an emergency CS [7].

It also seems useful to examine how the lower-

order AS factors might relate to FOC. For example,

individuals who fear the physical symptoms of

anxiety may be fearful of childbirth, given the

numerous somatic sensations associated with the

delivery process. Similarly, those who fear the social

consequences of anxiety symptoms (e.g., being

Fear of childbirth 169

embarrassed) may experience FOC because they are

afraid of how they will present themselves to others

during the delivery [17]. Finally, women who are

afraid of the psychological symptoms of anxiety (e.g.,

fear of going crazy) may experience FOC because of

an inappropriate fear of losing control [17] or of

being unable to cope psychologically with the

delivery.

The purpose of this study was to specifically

examine the relationship between AS and FOC to

explore whether there is support for the hypothesis

that AS is a risk factor for FOC. We were interested

in examining the relationship between AS and FOC

after controlling for the effects of background

variables. Furthermore, we explored the possibility

that trait anxiety would not be a significant predictor

of FOC if AS was controlled for. The rationale for

this is that AS is regarded as a fundamental fear that

predisposes individuals to other common fears. It

was hypothesised that all lower-order AS dimensions

would significantly predict prenatal FOC over-and-

above prior childbirth history and trait anxiety.

Method

Participants and procedure

A sample of 110 women from Regina, Saskatchewan,

Canada between the ages of 18 and 42 years

(M¼ 29.4) and in the final 4 months of their

pregnancy, participated in the study. Both parous

(n¼ 66) and nulliparous (n¼ 44) women were

included in the sample. To ensure variability in the

sample, half of the participants (n¼ 55) were

recruited from community obstetric practices and

the remaining participants (n¼ 55) were recruited

from a clinic specialising in the treatment of pregnant

women with previous or current pregnancy compli-

cations. Participants were asked to indicate if they

had any complications with a previous or current

pregnancy and to list said complication(s). Thirty-

four of the 110 women reported having a complica-

tion with the current pregnancy that had already

manifested at the time of enrolment in the study.

Complications that women listed included gesta-

tional diabetes, bleeding and obstetric cholestasis.

Forty-two of the 110 participants reported having a

complication with a previous pregnancy, and those

listed included miscarriage(s) and CS. Seven of the

110 women reported using assisted reproductive

technologies to become pregnant, including in vitro

fertilisation and follicle stimulation. No category was

large enough to permit analyses of predictors of FOC

within specific subcategories of complication type or

assisted reproductive method type.

Participants were asked to complete a set of ques-

tionnaires, consisting of the Anxiety Sensitivity Index

(ASI), State-Trait Anxiety Inventory-Trait Subscale

(STAI-T), and version A of the Wijma Delivery

Expectancy/Experience Questionnaire (W-DEQ).

Measures

Anxiety sensitivity. The ASI is a 16-item self-report

measure of AS with items rated on a five-point Likert

scale ranging from zero (very little) to four (very

much) [22]. The ASI consists of three subscales:

physical, psychological and social concerns [27]. The

ASI has test–retest reliability in the 0.71 to 0.75

range and is a well-established predictive measure of

fearfulness [22]. The internal consistency coefficients

in this study were 0.88 for the physical concerns,

0.85 for the psychological concerns and 0.61 for the

social concerns subscales.

Trait anxiety. The STAI-T is a brief self-report

inventory designed to measure trait anxiety [16],

defined as individual differences in the frequency and

intensity with which anxiety, apprehension and

tension manifests itself over time [33]. The STAI-T

consists of 20 statements describing how people

generally feel rated on a four-point frequency scale

ranging from almost never to almost always. The

STAI-T has good reliability and validity [16]. The

internal consistency coefficient for the STAI-T was

0.94 for the present study.

Fear of childbirth. The W-DEQ (version A) is a 33-

item form assessing FOC based on the respondent’s

cognitive appraisal and expectancies about delivery

[34]. Responses are rated on a six-point Likert scale.

Items focus on how the participant imagines the

pending labour and delivery. The W-DEQ was found

to have good internal consistency and split-half

reliability in a sample of 196 pregnant women [34]

and considerable evidence supports its validity [5]. In

this study, the internal consistency coefficient for the

WDEQ was 0.91.

Results

Fear of childbirth and demographic variables

Ten women or 9.1% of our sample met criteria for

FOC in the severe range using the cut off score of

�85 on the W-DEQ [4]. Prior to hypothesis testing,

we examined the relations between background

variables and FOC. Pearson correlation coefficients

were calculated to examine the relationship between

FOC and continuous variables and point-biserial

correlations were calculated to examine the relation-

ship between FOC and dichotomous variables. As

can be seen in Table I, FOC was significantly greater

among participants who were expecting their first

child. FOC was not, however, significantly greater

among older participants, those who were further

170 K. Spice et al.

along in their pregnancy, those who had complica-

tions with the current or an earlier pregnancy or

those who attended a speciality clinic.

Regression analysis

A hierarchical multiple regression was conducted

with W-DEQ scores as the dependent variable

(see Table II for the regression table). This regres-

sion consisted of three steps. In the first step, we

entered whether the woman was expecting her first

child because this was the only background variable

identified as related to FOC in the above correla-

tions. At the first step, as one would expect we found

that expecting a first child was a predictor of FOC;

that is women who were expecting their first child

reported greater FOC. In the second step, scores on

ASI subscales were entered and there was a

significant increase in variance explained. AS-physi-

cal concerns were identified as a significant predictor

of FOC in addition to expecting a first child. In the

third and final step, we examined whether trait

anxiety would explain variance in FOC above-and-

beyond parity and AS dimensions. There was a

statistically significant increase in variance explained

in FOC. In the final model, FOC was found to be

greatest among women who were expecting their first

child (b¼ 0.25, p5 0.01), who had greater trait

anxiety (b¼ 0.44, p5 0.01) and also who had higher

AS-physical concerns (b¼ 0.25, p5 0.03).

Discussion

The present research focussed on FOC, which is

estimated to be a concern for as many as 33% of

women [2], and of severe intensity in as many as 11–

14% of pregnant women [4,5]. FOC is an important

construct to understand especially because of its

relationship to negative birth experiences and post-

natal distress [11] and also its relationship to elective

and emergency CSs, which can be both risky and

often unnecessary compared to a vaginal birth [7]. In

the current sample, severe FOC was identified in

*9% of women, which is comparable to rates found

by previous researchers using the W-DEQ [4,5].

Table I. Correlations among variables studied.

Age

Weeks

pregnant

Pregnancy

complications

Recruit

site

ASI-physical

concerns

ASI-psych.

concerns

ASI-social

concerns

STAI-T

anxiety

W-DEQ fear

of childbirth Parity

Age – 0.15 0.16 0.06 0.11 70.07 70.05 70.01 0.03 70.19

Weeks pregnant – 70.07 70.17 70.04 70.11 70.08 0.02 70.06 70.02

Pregnancy

complications

– 0.43** 0.29** 0.16 0.27** 0.19 0.09 70.02

Recruit site

(0¼ community;

1¼ speciality)

– 0.16 0.19 0.13 0.13 0.06 70.22

ASI physical

concerns

– 0.69** 0.63** 0.57** 0.45** 70.06

ASI psychological

concerns

– 0.52** 0.55** 0.39** 70.04

ASI social concerns – 0.48** 0.28** 0.03

STAI-T anxiety – 0.55** 0.03

W-DEQ fear of

childbirth

– 0.24*

Parity (0¼not first

child; 1¼first

child)

–

*p5 0.05; **p50.001.

Table II. Parity, anxiety sensitivity and trait anxiety as predictors of

prenatal fear of childbirth.

Dependent variable b t p R2 AdjR2 DR2

Fear of childbirth

Step 1 0.06 0.05 0.06

Expecting first

child

0.25 2.67 0.01

Step 2 0.29 0.26 0.23

Expecting first

child

0.27 3.23 0.00

AS-physical

concerns

0.38 2.93 0.00

AS-psychological

concerns

0.17 1.48 0.14

AS-social concerns 70.06 70.56 0.58

Step 3 0.40 0.37 0.17

Expecting first

child

0.25 3.23 0.00

AS-physical

concerns

0.25 2.01 0.04

AS-psychological

concerns

0.05 0.47 0.64

AS-social

concerns

70.13 71.28 0.20

STAI-trait 0.44 4.45 0.00

Fear of childbirth 171

In examining the relationship between FOC and

AS, it was found that considerable variance in FOC

can be accounted for by whether a woman is

expecting her first child, AS-physical concerns and

trait anxiety. The findings confirm previous research

demonstrating that expecting a first child is associated

with higher levels of FOC [1,2,9,17] and that elevated

trait anxiety may increase the likelihood that a woman

will experience FOC [18,35]. However, this study

refines earlier work by specifically examining AS. By

taking AS into account, further variance in FOC was

explained in addition to women’s parity and level of

trait anxiety. This is particularly interesting in light of

the expectancy model of fear [21], which suggests that

AS is a fundamental fear that should be considered in

understanding the development of other fears. How-

ever, the evidence suggests that AS should not replace

consideration of trait anxiety in models that attempt

to predict specific fears. With that said, the findings

remain consistent with earlier research indicating that

AS may be a risk factor for fearfulness [22], given that

AS was a significant predictor of FOC, even after

accounting for effects of trait anxiety.

Limitations

This study did not examine AS in the context of

other variables (e.g., social support, socioeconomic

status, fear of pain) that may be important in the

development of FOC. Furthermore, data regarding

obstetrical outcomes was not collected; thus it is not

known whether women high in FOC requested a CS,

if they were granted their delivery preference, or how

these women with elevated FOC coped during their

pregnancy, in childbirth or the post-natal period.

Given that this is the first study that has sought to

explore the relationship between AS and FOC

directly, it remains for future research to develop

and test more comprehensive models for under-

standing this fear. This study suggests, however, that

AS-physical concerns should be included in such

models given that it contributes to the prediction of

FOC even when considered along with trait anxiety

and parity of the mother.

A second and important limitation of this study

was the use of the original ASI. This tool has well-

established psychometric properties as a measure of

AS [36], but the reliability of the social concerns

scale, although acceptable, was nevertheless lower

than other scales used in this study. Future research

on this topic should assess AS using the ASI-3 [37] –

a longer measure with higher internal consistencies

for the three lower-order factors.

Clinical implications

It is important to note that not all fears of childbirth

are irrational, and thus it is essential for clinicians

who are working with mothers who appear to have

FOC to conduct a careful physical and psychological

examination. Particularly important during this

assessment is to ensure that physical complaints

are, indeed, a symptom of the fear or heightened

sensitivity to normal physical sensations rather than a

result of a pregnancy complication [11].

This appears exceptionally important, considering

the current study’s results suggesting that AS predicts

FOC primarily because of fear of physical symptoms,

rather than fear of social consequences of anxiety

symptoms (e.g., being embarrassed) or of psycholo-

gical symptoms of anxiety (e.g., fear of going crazy or

losing control). Thus, careful consideration and liai-

son between the treating obstetrician and psycholo-

gist or psychiatrist, is necessary when assessing FOC.

If FOC is found to be a problem after a thorough

assessment is conducted, treatment of AS-physical

concerns may prove to be beneficial. Previous

research suggests that AS-physical concerns can be

reduced successfully with exposure to physiological

symptoms [38] – a technique referred to as ‘inter-

oceptive exposure’ [39]. In addition, past research

has shown that treating AS in a brief intervention

involving a combination of psychoeducation, cogni-

tive restructuring and interoceptive exposure is

effective not only for reducing high AS levels, but

also for lowering high AS women’s fear of pain [39].

It would be valuable for future research to explore

whether similar methods may be helpful for reducing

FOC, particularly for women with high scores on the

AS-physical concerns subscale.

Ultimately, we hope that a better understanding of

FOC will lead to enhanced treatment of this type of

fear. There are multiple benefits that could potentially

arise from treating FOC. Namely, successful treat-

ment of FOC may allow women to make a decision

about undergoing an elective CS with fears of

childbirth having a diminished influence on their

preference. Moreover, treatment of FOC has poten-

tial to result in increased satisfaction with delivery and

may reduce the postnatal distress experienced by

some women [11]. This, in turn, could positively

impact the quality of life of mothers and their children

and ultimately reduce the likelihood that more

debilitating psychological disorders will develop.

Declaration of interest: The authors report no

conflicts of interest. The authors alone are respon-

sible for the content and writing of the article.

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Fear of childbirth 173

Current knowledge on this subject

. Fear of childbirth (FOC) is known to complicate the delivery process (e.g., increasing risk for caesarean

section). Roughly 33% of women admit to being fearful of childbirth, with anxiety peaking during the

last trimester. Between 11 and 14% of women present with severe FOC that can be highly disabling.

Predictors of FOC are manifold. FOC differs among women who have previously given birth (parous)

when compared with women who are expecting their first child (nulliparous). Specifically, nulliparous

women report higher levels of FOC than parous women. Trait anxiety, or the relatively stable

disposition to be anxious, also has been linked to FOC. Consequently, moderate to extreme FOC has

been related to a number of anxiety disorders and phobias, including PTSD, blood phobia, animal

phobia and agoraphobia without a history of panic disorder.

What this study adds

. To date, the relationship between anxiety sensitivity (AS) and FOC has not been examined. AS is the

fear of anxiety-related bodily sensations (e.g., heart palpitations, dizziness) that result from beliefs that

these sensations or anxiety experiences have harmful somatic, psychological or social consequences. In

the current sample, severe FOC was present in *9% of women, which is comparable to rates found by

previous researchers using the W-DEQ. Furthermore, findings of the present study confirm previous

research demonstrating that nulliparous women report higher levels of FOC than parous women and

that trait anxiety may predispose a woman to experience FOC. However, this study refines earlier work

by specifically examining AS in addition to trait anxiety. By taking AS into account, further variance in

FOC was explained in addition to women’s parity and trait anxiety. This finding is important and

specifically may suggest that, to effectively treat FOC, attention should be given to AS.

174 K. Spice et al.