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Alasan Cemas 100 Bumil
Alasan Cemas 100 Bumil
18 (1997) 266-272
Center for Women and Children's Health, Department of Obstetrics and Gynecology,
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correspondenceto:Dr B. SjCigrcn, Center for =men and Children's Health. apartment of Obstetrics and Gynecology. Karolinska
Hospital. S17176 Stockholm
266
Reasonsfor anxiety about childbirth Sj6gren
A greater understanding of the reasons behind the first interview, the women were always asked to
anxiety about childbirth is also important because describe in detail their fears about the impending
anxiety during labor may upset the woman during delivery and to describe previous deliveries.
pregnancy and contribute to complications, e.g. Sometimes it w a s possible to discuss important
ineffective uterine contraction^".^. The aims of the relationships, e.g. with her partner or own mother,
present study were, firstly, to define the major as early as in the first interview. During subsequent
conscious factors behind the severe anxiety over sessions, the information from the first interview
childbirth in order to find models of treatment and was confirmed and more delicate issues which
support during the pregnancy, and, secondly, to which could be raised, such as attitudes towards
assess the role of previous obstetrical complications. motherhood. Many very sensitive issues were
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The hypotheses were that a pattern regarding the approached indirectly, e.g. asking whether her
anxiety would be recognized and that differences mother’s deliveries were difficult or complicated,
would be found between primiparae and women which could elicit a response such as ‘she has never
with previous complicated or uncomplicated deliv- told me anything about it, and I would not like to
eries. Moreover, some guidance for future studies discuss such matters with her now either’.
would be found. It was observed if the women suffered from a
current emotional crisis, due to a negative life
event. It could be the recent death of a parent,
METHODS
recent loss of a fetus or serious problems in the
The study sample comprised a consecutive series of relationship with the partner and doubts about the
100 women referred to the Psychosomatic future ofthe relationship. It could also be a result of
Outpatient Clinic of the Department of Obstetrics some earlier psychological crisis, obviously reacti-
and Gynecology, Karolinska Hospital, Stockholm, vated by the pregnancy and impending delivery, e.g.
For personal use only.
between October 1989and March 1992. They were death of a parent during the woman’s childhood or
referred because of severe anxiety about the teens, or a particularly painful and complicated
impending childbirth, regardless of the author’s relationship with her own mother. These psychic
intention of collecting material for a study. The problems are defined in the system of psychiatric
women were extremely distressed and unable to diagnosis (DSM W).
look forward to the arrival of their babies. They had The women were assessed as likely to benefit
difficulty in sleeping, nightmares, o r were from psychotherapy, and 25 accepted and under-
preoccupied with thoughts of a surgical delivery. went conventional psychotherapy5. Important
The gynecologists and midwives providing routine information was also obtained during these psycho-
antenatal care were unable to manage this anxiety. therapy sessions and reported at regular meetings
The time for referral varied between weeks 20 between the therapist and the psychosomatic
and 35 of gestation. A detailed, systematic obstet- gynecologist. All information was written up
rical and psychological history was taken by the systematically in detailed records, in order to
author (obstetrician/gynecologist, trained in facilitate follow-up. The records were stored
psychotherapy). All the women had at least one confidentially, separate from the ordinary medical
consultation of 45-60 min duration with the records. After the delivery of the 100 women, the
gynecologist (author). The median number of data from the psychosomatic records were
interviews was 3.4 (range 1-10). During the analyzed. The study was inspected by the Ethics
antenatal psychosomatic treatment at the hospital, Committee of The Karolinska Hospital.
the women continued their contact with the
midwife and obstetrician at their regular antenatal
Statistics
clinics. In many cases, the obstetrical condition was
discussed with the chief obstetrician at the hospital. For comparison between subgroups of the sample,
T h e clinical interviews focused on social non-parametric methods, Chi-square test, Fisher’s
situation, and previous and current mental health. exact probability test9, and Chi-square test for exact
The women’s fears and thoughts about childbirth significance testing of heterogeneity for ordered
were investigated in in-depth interviews and categorical datalo were applied. All tests were two-
discussed as intimately as the women allowed. In tailed.
had given birth, with a high frequency of previous not presented in table). The next most fiequent
complications (Table 1). The results are presented focus of anxiety, reported by 65%, was that they
for three groups, primiparae (n = 36), women with would prove incapable of giving birth (Table 2).
a normal delivery (n=18) and women with a They fcved that their bodies would be inadequate
complicated delivery (n = 46). The subgroups were or that they would suffer injury (390h),or that they
similar in all but one aspect: significantly more of would not perform well due to psychological
the primiparous women had had a previous reasons (26%, no significant differences between
voluntary abortion (Table 1). subgroups, data not in table). More than half of the
women (55%) described fear of death: their own
Major reasons for fear of delivery and (9%) or that of the infant (30%), or of both (16%).
Anxiety about disaster and death was significantly
psychological health
more frequent among parous women who had
Previous psychological problems (e.g. periods of experienced a complicated delivery (p < 0.001).
For personal use only.
mental depression, panic disorder) and current Expectations of intolerable physical pain were
emotional crises due to a recent life event were expressed by 44% of the women. A similar
identified and are shown in Table 2. There w a s no proportion feared losing control of the situation, or
significant difference between the subgroups with the development of total chaos during the delivery,
respect to previous mental problems and current either on their own part or by the attending hospital
Table 1 0b;tetrical history and social status of 100 women with severe fear of childbirth The three sub-groups are
compared by means ofChi-square test for exact signiiance testing ofheterogeneityfor ordered categorical data9.Siplicant
differenceis considered when p < 0.05
Pnvwus delivny
None Uncomplicated Complicated Toull number p value
(n =36) (n = 18) (n = 46) (n = 100)
Stable partnership 33 13 46 92 NS
Education
university, > 15 years 14 7 17 38 NS
intermediate, 12years 15 5 15 35
elementary, 9 years 4 2 8 14
no answer 3 2 6 11
Involuntary infertility ’ 4 0 3 6 NS
Miscarriage 6 5 8 19 NS
Voluntary abortions 20 4 14 38 0.021
Employed 35 17 44 86 NS
Unemployed 1 1 2 4 -
Parents leave 0 2 8 10 NS
Previous perinatai death or late miscarriage 2 2 9 13 NS
Feeling of chaos in previous delivery - 1 6 7 NS
Fear of death in previous delivery
(infant’s or own) - 1 14 15 0.09 trend
NS. not significant
Table 2 Age, psychic problems and negative expectations regarding the impending delivery in three subgroups ofwomen
with severe fear of childbirth. One woman could report more than one reason for anxiety The three groups are compared
by means of Chi-square test for exact significance testing of heterogeneity for ordered categorical data9
Previous deliwry
None Uncomplicated Complicuted Total number p value
(n = 36) (n = 18) (n = 46) ( n = 100)
lack of trust 24 12 37 73 NS
incompetence of giving birth 24 10 32 65 NS
fear of death 15 4 36 55 <0.001
intolerable pain 17 8 19 44 NS
loss of control 17 4 22 43 NS
NS, not significant
sta& Anxiety over physical pain and loss of control, control (58% and 29%, respectively, p c 0.05, data
bodily incapacity or injury, and fear of poor not presented in table). The women who had felt
performance were similar in the groups (Table 1). anxiety about death more often had a partner who
Pronounced ambivalence about the maternal role was afraid of the delivery (61%, 18%, respectively,
was indicated by 21 women. Twenty-nine women p < 0.01). However, these women reported a lower,
For personal use only.
knew that one or more of their own mother's not statistically significant frequency of expectation
deliveries had been complicated or difficult (not in of intolerable pain than the other women (33%and
table). 54%, respectively, p = 0.08). They also had a lower
frequency of negative expectations of injury or
physical inadequacy than the other women (30%
Partner's role
and 46%, respectively, p = 0.1). These differences
The partners of more than half of the women did not approach significance. Of those who had
(55%) participated in the discussion about the actually experienced perinatal death, 82%, but not
delivery. Thirty-seven per cent had a partner who all, described anxiety about death in the previous
frankly admitted his own anxiety over the impend- delivery.
ing delivery, and 22% a partner who requested or
demanded CS. The partners of the women who
DISCUSSION
had experienced a previous complicated delivery
were significantly more often anxious than the As most pregnant women are preoccupied with the
partners in the other subgroups (p = 0.044, data not delivery during their entire pregnancy, and most
presented in table). intensively during the final trimester", this must be
regarded as a normal phenomenon. However, the
fear described by the women in the present study,
Influence of anxiety about death during a
so extreme that it could not be managed by routine
previous delivery
antenatal care, must be regarded as a condition
Some differences were found between the parous different from the normal emotional preparation
women who had felt anxiety about death during for childbirth. The present study showed firstly that
previous childbirth and those who had not: the in a consecutive series of 100 women with 'fear of
former were - not unexpectedly - more frequently childbirth, almost half (46%) had had a previous
preoccupied with this fear in relation to the coming complicated childbirth. Secondly, a number of
delivery (100% and 21%, respectively, p c 0.001). different contents of the fear were elicited: 73% of
They also more frequently reported fear of loss of the women reported lack of trust about the
obstetric team and their providing adequate this study the stress theory might be applicable in
support, and 65% of the women feared that they cases of fear of childbirth, not on the objective
would prove physically or mentally incapable of trauma but on the perceived trauma of a previous
giving birth. Fear of death was expressed by 55%, delivery.
loss of control during delivery was feared by 44% As described elsewhere, the women in the
and expectation of intolerable pain was expressed present study had a significantly higher frequency
by 43%. Fear of death was significantly more of previous psychological problems than the
frequent among those who had had a previous controls, indicating a greater vulnerability5.
complicated delivery Otherwise, there was a great Previously, negative experience of childhood and of
similarity between the subgroups. sexuality has been associated with fear of
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The results are in accordance with the findings of childbirth". The findings of lack of basic trust and
an earlier Swedish study reporting that 80% of the fear of death were central themes of the anxiety in
women with fear of childbirth had a history of a the present study Recently, similar results regarding
complicated previous delivery4. Another study lack of trust were obtained from about 33 women
found a correlation between vaginal or operative with anxiety over ~hildbirth'~. In comparison, a
interventions and disappointment over deliverygf. s t u d y of 122 non-selected pregnant women found
All these data justify the application of the stress that the majority denied fear of feeling helpless and
theory, including the concept of post-traumatic misunderstoodI2.In cases where no traumatic event
stress disordeP. A recent Swedish study found that could be identified, other theories might be useful
76% of women who had undergone emergency CS and could be discussed in order to understand the
had experienced their delivery as a traumatic event. psychological determinants of intense fear of
A completely developed post-traumatic stress childbirth. One of them, the psychoanalytical
disorder could not be identified, but 33%ofwomen theory, has proposed that all fear of childbirth might
For personal use only.
were found to suffer from post-traumatic stress be expressions of a deep fear of death which has
reactions 6 weeks after an emergency CS". The been transmitted through many generationsls. The
present study, showing that the women with a fears, however, might be considerably reinforced by
previous complicated delivery more often had fear individual experiences in early childhood, which
of death regarding the future delivery and that this made the women particularly vulnerable to the
fear was correlated to a similar experience in a inevitable fears during pregnancy. If she, as an
previous delivery, indicated that their anxiety might infant herself, did not meet a 'good enough holding
be related to the stress disorder. envir~nment"~, lack of trust might develop. The
Complicated deliveries do not always seem to fear of loss of control might indicate a similar
result in long-standing severe reactions''. It may feeling of emotional and physical insecurity In
therefore be assumed that the anxiety of the women cases where these theories were applied, the stress
with a complicated previous delivery had some theory is not contradicted. The women might have
additional psychological determinants. This experienced traumatic events during other deliveries.
assumption is supported by the finding that a great A complicated attitude towards delivery might
propomon of parous women with anxiety about depend on ambivalence towards childbirth and
childbirth had already been anxious during the first might increase a woman's anxiety during preg-
pregnancyI5. Regarding women with a normal nancy. Women may feel various degrees of ambi-
previous delivery and nulliparous women also, the valence towards accepting the maternal role and
underlying reasons for anxiety could be elicited by some ambivalence might be naturalgllO.Twenty-
investigating the individual personalities and life one per cent of the women in the present study
experiences and by applying modem stress theory admitted a considerable ambivalence towards
as well as the psychoanalytic model. A previous reproduction. Moreover, the primiparae in the
delivery might have been diagnosed as normal, but present study were older (mean 32 years) than the
the women could have experienced it as a traumatic average primigravidae in Sweden (mean 26.1
event In a study of victims of t d i c accidents, the yearsf') and they had signlficandy more o k n had a
intensity of the stress reaction correlated to the previous voluntary abortion, which might indicate
perceived seriousness of the trauma but not to the ambivalence. A strong ambivalence in primipane
objective seriousnessg6.Again, in accordance with could be understood in terms of psychoanalytical
Statistical Manual of Mental Disorders (4th ed). 17. Areskog B, Uddenberg N, Kjessler B. Background
Washington. DC; American Psychiatric Association factors in pregnant women with and without fear
1993. of childbirth. J Psychosom Obstet Gynecol 19839:
9. Siege1 S. Nonparametric Statistics far the Behaviounl 101-8.
Sciences. NewYork McGraw Hill 1976. 18. Deutsch H. The Psychology of Women. A
10. Mehta CR,Pate1 NR. Tsiatis M Exact significance Psychoanalytic Interpretation. Vol II, Motherhood.
testing to establish treatment equivalence for ordered London: Research Books Ltd 1947190.
categorial data. Biometrics 1984,40:819-25. 19. Wmnicott DW The Child and the Family London:
11. Shereshefsky P.Y m LJ. Psychological Aspects of a Tavistock, 196712-33.
First Pregnancy and Early Postnatal Adaption. New 20. W h a n M, Jacobsson L, Joelsson J, von Schoultz B.
York Raven Press 1973. Ambivalence towards parenthood among pregnant
J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by Universitat Autonoma Barcelona on 11/04/14
12. Neuhaus W,Scharkus S,Hamm W, Bolte A. Prenatal women and their men. Act? Obstet Gynecol Scand
expectations and fears in pregnant women. J Perinat 1993;72619-26.
Med 1994;22:409-14. 21. SjiigTen B. Motherhood: when is the right moment
13. Davidson JRT, Foa EB. Posttraumatic Stress in women’s life? The gynaecologist x a counsellor in
Disorder. DSM Tv and Beyond. Washington, DC; the 1990s. In: Nijs P, LCysen B, Richter D, eds.
American Psychiatric Press 1993. Advanced Research in Psychosomatic Obstetrics and
14. Ryding EL,Wgma B, Wjma K. Posttraumatic stress Gynaecology. Leuven: Uigeverij Peeters 199123-6.
reactions after emergency cesarean section. Acta 22. Klein M. Early stages of the Oedipus conflict. In:
Obstet Gynecol Scand. 1997;7&856-61. Love, Guilt and Reparation and Other Works
15. Ryding EL. Investigation of 33 women who 1921-1945. London: Hoghart Press 197533-4.368.
demanded a cesarean section for persod reasons. 23. Irigaray L. Pouvoir du discours, subordination du
Acta Obstet Gynecol Scand 1993;72:280-5. ferninin, ce sexe qui n’en a t pas un. Paris: Editions
16. Malt U, Olafsen 0. Psychological appraisal and de Minuit 1977:lO-42.
emotional response to psychical injury: a clinical,
For personal use only.