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Childbirth Fear, Anxiety, Fatigue, and Sleep Deprivation in Pregnant Women
JOGNN
RESEARCH
Childbirth Fear, Anxiety, Fatigue, and Sleep Deprivation in Pregnant Women Wendy A. Hall, Yvonne L. Hauck, Elaine M. Carty, Eileen K. Hutton, Jennifer Fenwick, and Kathrin Stoll
Correspondence Wendy A. Hall, T. 201, 2211, University of British Columbia School of Nursing, Wesbrook Mall, Vancouver, British Columbia, Canada V6T 2B5. [email protected] Keywords childbirth fear anxiety fatigue sleep deprivation pregnancy
ABSTRACT Objective: To explore women’s levels of childbirth fear, sleep deprivation, anxiety, and fatigue and their relationships during the third trimester of pregnancy. Design: A cross-sectional descriptive survey of a community sample. Participants: Six hundred and fifty English-speaking nulliparous and multiparous women, 17 to 46 years of age and between 35 and 39 weeks gestation, with uncomplicated pregnancies. Methods: Wijma Delivery Expectancy/Experience Questionnaire, Spielberger State Anxiety Mindell’s Sleep Questionnaire, and the Multidimensional Assessment of Fatigue Questionnaire.
Inventory,
Results: Twenty-five percent of women reported high levels of childbirth fear and 20.6% reported sleeping less than 6 hours per night. Childbirth fear, fatigue, sleep deprivation, and anxiety were positively correlated. Fewer women attending midwives reported severe fear of childbirth than those attending obstetricians. Women with high childbirth fear were more likely to have more daily stressors, anxiety, and fatigue, as well as less help. Higher levels of anxiety predicted higher levels of childbirth fear among women. Conclusion: One fourth of women reported high childbirth fear. Women’s fear of childbirth was related to fatigue, available help, stressors, and anxiety. Fear of childbirth appears to be part of a complex picture of women’s emotional experiences during pregnancy.
JOGNN, 38, 567-576; 2009. DOI: 10.1111/j.1552-6909.2009.01054.x Accepted July 2009
s rates of Cesarean deliveries increase around the world, researchers and clinicians contemplate possible explanations. For example, rates of childbirth interventions are steadily increasing in Canada, with a national Cesarean birth rate of 26% (Canadian Institute for Health Information, 2007). Psychological factors, such as fear and anxiety around the childbirth process (Andersson, Sundstrom-Poromaa, Wul¡, —str˛m, & Bixo, 2004; Ryding, Wijma, Wijma, & Rydhstr˛m, 1998; Saisto & Halmesmki, 2003), sleep deprivation, or fatigue (Chien & Ko, 2004; Lee & Gay, 2004) have been implicated in increased childbirth interventions. Although each of these factors has been examined in relation to childbirth outcomes, relationships among childbirth fear, anxiety, sleep deprivation, and fatigue have not been studied, and combined contributions of these variables have not been examined in relation to birth outcomes.
A Wendy A. Hall, PhD, RN, is a professor at the University of British Columbia School of Nursing, Vancouver, British Columbia, Canada. Yvonne. L. Hauck, PhD, RM, RN, is a professor in the School of Population Health, University of Western Australia, Perth, Western Australia. Elaine M. Carty, MN, RN, is a professor emeritus, at the University of British Columbia School of Nursing, Vancouver, British Columbia, Canada. (Continued)
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The purpose of the study was to examine relationships among women’s childbirth fear, sleep deprivation, fatigue, and state anxiety in a sample of 650 pregnant women in the province of British Columbia (BC). The variables for the ¢rst phase of the study were identi¢ed to enable prospective examination of e¡ects of childbirth fear, anxiety, sleep deprivation, and fatigue on childbirth outcomes. A second phase of the study is currently underway where the birth records of the study participants are being obtained to provide data on birth outcomes. Fear of childbirth has been attributed to fear of pain, psychological factors, such as fear of future parenthood, and social factors, such as lack of support (Saisto & Halmesmki, 2003). Wijma, Wijma, and Zar (1998) argued that fear of childbirth occupies a domain separate from anxiety and arises from women’s expectancies and appraisals of speci¢c
& 2009 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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This study examined relationships among women’s childbirth fear, sleep deprivation, fatigue, and state anxiety. childbirth experiences. In support of their argument, in a small sample of pregnant women, trait anxiety correlated with childbirth self-e⁄cacy and the total score for a measure of pregnancy and childbirth-related anxiety but did not correlate speci¢cally with a subscale measuring pain, fear, and loss of control during labor (Beebe, Lee, Carrieri-Kohlman, & Humphreys, 2007). Factors associated with childbirth fear have included young maternal age, low education, lack of social support, high numbers of daily stressors, dissatisfaction with partner relationships, unemployment, smoking, poor self-rated health, and anxiety (Laursen, Hedegaard, & Johansen, 2008; Saisto & Halmesmki; Saisto, SalmelaAro, Nurmi, & Halmesmki, 2001). Childbirth fear has been studied in many countries with di¡erent ¢ndings. For example, the incidence of childbirth fear has been reported at 52% in a sample of 280 women in the United States (Lowe, 2000), 10% in a sample of 2,662 Finnish women (Waldenstr˛m, Hildingsson, & Ryding, 2006), and 5% in a sample of 8,000 Swiss women (Geissbeuhler & Eberhard, 2002). These di¡erences could be attributed to cultural factors or to the use of di¡erent measures in studies. For example, the Swiss study used a single question to ask about levels of fear of childbirth, whereas the American study used a modi¢ed fear of childbirth questionnaire with cut-o¡ scores for high and low childbirth fear. Zar, Wijma, and Wijma (2001) reported 20% of women in developed countries, such as Sweden and Australia, experience childbirth fear. Eileen K. Hutton, PhD, RN, is an associate professor of obstetrics and gynecology and assistant dean in the Midwifery Education Program, McMaster University, Hamilton, Ontario, Canada. Jennifer Fenwick, PhD, RM, RN, is an associate professor, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Australia. Kathrin Stoll, is a PhD student in interdisciplinary studies at the University of British Columbia.
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An association between anxiety and fear of childbirth has been reported by several authors (Andersson et al., 2004; Fairbrother & Woody, 2007; Johnson & Slade, 2003; Ryding et al., 1998). State anxiety captures anxiety at a given point in time, whereas trait anxiety refers to a stable personality trait (Spielberger, Gorsuch, & Lushene, 1983). The State Anxiety Measure has been used in several studies of pregnancy with di¡ering results. For example, a study by Canals, Esparo, and FernandezBallart (2002) identi¢ed no signi¢cant di¡erences in state anxiety between nulliparous and multiparous women during the last 3 months of pregnancy. In a study of socially high-risk pregnant women, state anxiety was associated with younger maternal age and stressors such as being pregnant, worry about money, and concern about
infant health (Bowen, Bowen, Maslany, & Muhajarine, 2008); these factors have also been related to childbirth fear. In terms of birth outcomes, state anxiety has been associated with an increased risk for planned Cesarean birth and length of labor (Andersson et al.). Johnson and Slade conducted an extensive review of anxiety and obstetric complications and concluded that fear of childbirth is a distinct dimension of anxiety that has implications for the delivery experience. Although sleep deprivation and fatigue during pregnancy have separately been associated with increased risk of obstetric interventions (Chien & Ko, 2004; Lee & Gay, 2004), no studies have examined these variables in relation to childbirth fear. Common sleep problems of the third trimester of pregnancy, such as nocturnal waking to void, di⁄culty getting comfortable, heartburn, and restless sleep due to fetal movement (Pien & Schwab, 2004) as well as conditions such as restless leg syndrome and obstructive sleep apnea (Mindell & Jacobsen, 2000;Pien & Schwab) lead to disrupted sleep and reduced energy levels (Beebe & Lee, 2007). Beebe and Lee reported more night waking was positively associated with response to pain and fatigue scores in a small sample of women in early labor. Moreover, fatigue levels during pregnancy have predicted Cesarean delivery (Chien & Ko), and sleep deprivation in late pregnancy (less than 6 hours per night) has increased women’s rates of Cesarean birth threefold compared with women without sleep deprivation (Lee & Gay). Links between childbirth fear, birth interventions, and other psychological factors, such as personality characteristics and sociodemographic factors, have been studied, but the relationships among childbirth fear and other contributing factors to birth interventions, such as fatigue and sleep deprivation, are not yet fully understood. The purpose of the ¢rst phase of this study was to describe the characteristics of 650 pregnant women, 35 to 39 weeks gestation, with respect to sleep, anxiety, fatigue, and childbirth fear. Speci¢c aims were to 1. describe women’s levels of childbirth fear; 2. describe women’s sleep deprivation; 3. examine relationships among levels of childbirth fear and sleep, anxiety, fatigue, and contextual factors, with the goal of identifying predictors of childbirth fear; and 4. examine similarities and di¡erences in nulliparous and multiparous women in terms of childbirth fear, sleep deprivation, anxiety, and fatigue.
JOGNN, 38, 567-576; 2009. DOI: 10.1111/j.1552-6909.2009.01054.x
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RESEARCH
Hall, W. A. et al.
Methods Design The study was a cross-sectional descriptive survey design.
Sample and Setting Women were recruited between May 2005 and July 2007 from communities across the province of BC that had 150 births or more annually. The community inclusion criterion was based on the estimated cost of sending materials to a community. The convenience sample included pregnant women who resided in BC at the time of data collection, could speak and read English, and were between 35 and 39 weeks gestation. Women who were experiencing high-risk conditions associated with their pregnancies (e.g., pregnancy-induced hypertension, preterm labor, bleeding, and type 1 diabetes), had a diagnosed sleep disorder, or worked continuous night shifts were excluded from the study. Women who contacted the study coordinator before the eligible gestational age were put on a wait list and contacted immediately before 35 weeks gestation to ascertain whether they were still interested in participating. A power calculation indicated that assuming medium e¡ect sizes and a 5 .05, a sample size of 150 would provide power (in excess of .85) for analysis of variance (ANOVA). The overall sample size exceeded the one determined by the power calculation for examining relationships among the variables to ensure an adequate sample would be available for the second phase of the study, which is intended to determine how the variables contributed prospectively to a number of birth outcomes.
Procedures The study was reviewed and approved by the University of British Columbia Ethical Review Board and BC Women’s and Children’s Hospital Ethics Committee. Study information was sent to care providers’ o⁄ces, antenatal education classes, online pregnancy and parenting resource sites, large companies, such as telephone and hydro companies, and provincial unions. Print media were also placed in maternity and children’s toy stores. Researchers attended community events for pregnant women and provided interviews about the study for radio, television, and newspapers. After receiving information from the study coordinator and consenting to participate, women were sent a package that included a consent form to provide permission to access their birth records (for followup study), demographic questions developed for
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this study, and standardized measurement tools including the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ, childbirth fear; Wijma et al., 1998), Spielberger’s State Anxiety Inventory (STAI-S; Spielberger et al., 1983), Mindell’s Sleep Questionnaire (Mindell & Jacobsen, 2000), and the Multidimensional Assessment of Fatigue (MAF scale; Belza, Curtis, Yelin, Epstein, & Gilliss, 1993). Questionnaires were returned by mail within a week or two of receiptçbefore the women gave birth. If questionnaires were not returned within 2 weeks, participants received reminder e-mails or phone calls on two occasions 2 weeks apart from the study coordinator to encourage them to return their questionnaires.
Measures Demographic data included maternal date of birth, personal health number, presence of a partner in the home, ethnicity, number of previous pregnancies, number of living children and their ages, geographic location, education level, family income, current employment status, a single item about help (number of people available for help), number and type of daily stressors (relationships, employment, ¢nances, education, and health), questions about previous adverse labor and birth experiences, type of primary care provider, a single item about attendance at childbirth education classes, and a single item for intentions regarding Cesarean birth and other birth-related interventions. The demographic form was developed by the investigators. The W-DEQ is a 33-item questionnaire that measures fear of childbirth on a 6-point likert scale using expectations about experiences during labor and birth (Zar et al., 2001). Scores equal to or lower than 37 indicate low fear, 38 to 65 indicate moderate fear, and equal to or higher than 66 represent high levels of fear. The internal consistency and split-half reliability of the W-DEQ has been high: greater than .94 in both nulliparous and multiparous women; the W-DEQ had support for construct validity, because it overlapped by 30% with trait anxiety in a sample of nulliparous and multiparous women, and in multiparous women, correlated highly with other measures of childbirth fear (r 5 .65-.78; Wijma et al.,1998). There is also evidence of its predictive validity, as pregnant women with intense fear of childbirth had a more negative perception of their births 1 week postbirth (Ryding, Wir¢eld, Wngborg, Sj˛ergn, & Edman, 2007). The STAI-S is one of the most widely used measures of subjective anxiety (Spielberger et al., 1983). The
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State inventory consists of 20 items that measure the anxiety at a given point in time, with the lowest score at 20 and the highest score at 80. The measure has extensive support for validity and reliability in the childbearing population, with internal consistencies as high as .92 (Canals et al., 2002). The choice of the STAI-S ¢ts with a review of obstetric complications and anxiety wherein Johnson and Slade (2003) argued that trait anxiety is unrelated to obstetric complications. Another study, where the correlation of the STAI-T with childbirth fear was at r 5 .05 (Johnson & Slade, 2002), also suggests anxiety represents a di¡erent construct than childbirth fear. Mindell’s Sleep Questionnaire was used to determine sleep deprivation (Mindell & Jacobsen, 2000). The questionnaire is speci¢cally designed for pregnant women and requests information about sleep patterns and disruptions during the previous 2 weeks. The instrument provides similar data to sleep diaries without requesting women to record their nighttime activities for several days. Cronbach’s as for the measure were reported at .52 for sleep patterns and .76 for sleep disordered breathing (Mindell & Jacobsen). No information was provided about the validity of the measure. The MAF scale is an instrument that measures fatigue severity, distress, degree of interference in activities of daily living, and timing (Belza et al., 1993). The preceding subscales combine to give a total fatigue score, with high scores equaling high levels of fatigue. In other studies of childbearing women, the measure has demonstrated high internal validity (a 5 .93-.96), sensitivity to changes in fatigue from pregnancy to 2 weeks postpartum, using one-way repeated-measures ANOVA, F(1,113) 5 25.66, po.001, and pre- and postsleep intervention, t(2, 69) 5 4.4, po.001 (Fairbrother, Hutton, Stoll, Hall, & Kluka, 2008; Hall, Clauson, Carty, Janssen, & Saunders, 2006), and convergent validity with the Pittsburgh Sleep Quality Index (r 5 .48-.64, po.001); it is considered valid for use in the pregnant population (Fairbrother et al.).
Analysis Statistical Package for the Social Sciences 16.0 was used for all statistical analyses. Interval data were summarized using means, standard deviations (SDs), medians, and interquartile ranges. Categorical data were summarized using frequency distributions. On the basis of scores on the W-DEQ, women were placed into high, moderate, or low childbirth fear groups by using fourth quartile scores that indicated high levels of fear (greater
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than or equal to 66), second and third quartile scores that indicated moderate levels of fear (3865), and ¢rst quartile scores that indicated low levels of childbirth fear (less than 37). Women were categorized as sleep deprived (less than 6 hours) versus non^sleep-deprived (greater than or equal to 6 hours) based on their average hours of night sleep calculated from the Mindell Sleep measure. The authors used cut-o¡ scores on the Mindell scale based on those used by Lee and Gay (2004), because they reported less than 6 hours of sleep per night increased the risk of Cesarean deliveries. The authors also calculated the proportions of women with interrupted sleep who were up three or more times per night (de¢ned as sleep fragmentation). For all analysis testing, a p value of .05 was accepted as signi¢cant. Pearson’s correlation coe⁄cients were calculated for childbirth fear, state anxiety, fatigue, and hours of sleep per night. Groups based on high, moderate, and low levels of childbirth fear were compared on number of stressors, number of people available for help, fatigue, sleep hours per week, and anxiety using a oneway multivariate analysis of variance (MANOVA). Chi-square analyses were used to compare groups on categorical variables, such as the care provider. Finally, hierarchical regression modeling was used to examine potential predictors of level of childbirth fear. Possible predictors included age, educational level, family income, parity, amount of sleep per week, available help, state anxiety, fatigue, and number of daily stressors. The selection of psychosocial predictor variables was based on the results of the bivariate analyses that indicated an association between a given predictor and childbirth fear. Sociodemographic predictor variables were selected on the basis of previous research.
Results Nine hundred and sixteen ¢rst-time and previously pregnant women responded to the recruitment techniques. Thirty women on the waitlist did not reach 35 weeks during their pregnancies by the time recruitment was suspended because the minimum sample size was exceeded based on power analysis and the funding ended. Twelve women became ineligible during their time on the waitlist for health reasons and two moved out of province. The authors were unable to contact 30 women. Two decided not to participate. A sample of 872 agreed to complete questionnaires, with 650 surveys returned with usable data (75%). The women who responded to the survey were on average 31.5 years old, predominantly Canadian
JOGNN, 38, 567-576; 2009. DOI: 10.1111/j.1552-6909.2009.01054.x
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RESEARCH
Hall, W. A. et al.
(69%), and well educated (over 50% had completed a university degree; see Table 1). Sixty percent were nulliparous and 40% were multiparous. Fiftytwo percent of the multiparous women described having di⁄cult labors with previous pregnancies. Approximately 25% of the sample had midwives as their primary care provider while 36% were seeing an obstetrician and 39% a family physician (see Table 1 for additional sample characteristics). In BC, under the medical services plan, women are able to choose a midwife or family physician as a primary care provider. An obstetrician becomes a primary care provider only on referral; however, family physicians who do not provide intrapartum care often refer low-risk women to obstetricians late in pregnancy. When the authors compared women by childbirth fear group and care provider the chisquare statistic was signi¢cant, w2 (4) 5 24.0, po .001, with 16% of midwifery clients in the high-fear group versus 35% of obstetricians’ clients. Seventy percent of the sample reported 1 to 3 daily stressors and 13% reported four or more. Moreover, 35% of the women reported relationships as a stressor and 51% reported ¢nances as a stressor. Of the women who did not have a previous Cesarean delivery, 4% planned to request Cesarean birth. Findings from the bivariate and multivariate analyses are organized according to the stated purposes of the study.
Characteristics of the Measures In this study, the mean for the W-DEQ was 52.87 (SD 5 19.66) and Cronbach’s a was .92. For the STAI-S, the mean was 35.56, with a SD of 10.33 and a Cronbach’s a of .93. For Mindell’s Sleep Questionnaire, a Cronbach’s alpha was not calculated because the authors used single items such as number of hours of sleep per night and number of waking times per night as variables of interest. For the MAF scale, the mean for the scale was 29.26 (SD 5 9.34) and the Cronbach’s a was .93. The ordering of the scales in the questionnaire was the STAI-S, W-DEQ, MAF, and Mindell’s Sleep Questionnaire.
Women’s Levels of Childbirth Fear Twenty-¢ve percent of the sample reported high levels of fear (n 5 162), while 54% reported moderate fear (n 5 349), and 21% low levels of childbirth fear (n 5 138).
Twenty-five percent of the sample reported high levels of childbirth fear, with 54% reporting moderate fear and only 21% low levels of fear.
Table 1: Demographic Characteristics of Sample Characteristics, Range (Mean) [Median] Age (years), 17-46 (31.5) [32] o25
8.5 (55)
25-35
70.7 (459)
435
20.8 (135)
Number of children, 0-4 (0.5) [0] None
59.7 (388)
One child
31.7 (206)
More than one child
By the de¢nition of a cut-o¡ score of less than 6 hours of sleep per night, 21% (n 5 134) of the sample reported being sleep deprived. Approximately 68% of the women (n 5 440) in this study
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8.6 (56)
Partner Yes
98.2 (638)
No
1.8 (12)
Education High school or less
8.8 (57)
College or less
28 (182)
University degree or less
45 (292)
Postgraduate degree
18.2 (118)
Family income o$20,000
2.7 (17)
$20,000-39,000
10.6 (67)
$40,000-59,000
17.3 (109)
$60,000-79,000
16.6 (105)
$80,000-99,000
19.8 (125)
4$100,000 Characteristics
33 (207) Percentages (n)
Ethnicity (self-identi¢ed) Aboriginal
2 (12)
African/Caribbean
2 (9)
Asian/Chinese
Women’s Sleep Deprivation
Percentages (n)
7.6 (49)
Canadian
69.4 (450)
European
12.6 (81)
Latin
1.5 (7)
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Table 2: Correlation Coefficients Among Primary Variables
Variables
Childbirth
Sleep Hours
Fear
per Night
Anxiety
Childbirth Fear Sleep Hours per Night
.12
Anxiety
.54
.22
Fatigue
.31
.22
.49
Note. po.001.
l 5 8.1, po.001). Follow-up tests revealed that multiparous women had signi¢cantly higher levels of fatigue (MAF score 5 31.3 vs. 27.9 for nulliparous), fewer hours of sleep (7.6 vs. 7.3), and more feelings of state anxiety (STAI-S 5 36.9 vs. 34.7); however, these di¡erences might not be large enough to be clinically meaningful. Moreover, there were no signi¢cant di¡erences between nulliparous and multiparous on sleep deprivation as indicated by a cut-o¡ score of less than 6 hours per night (p4.25).
Predictors of Childbirth Fear
indicated that they got up three or more times per night, which was de¢ned as sleep fragmentation.
Associations among childbirth fear, anxiety, sleep deprivation, fatigue, state anxiety, daily stressors, and available help The authors examined relationships among childbirth fear, sleep deprivation, state anxiety, and fatigue. All of the variables were signi¢cantly correlated with childbirth fear, though only state anxiety and fatigue displayed moderate to strong correlations (see Table 2). In addition, the MANOVA revealed signi¢cant di¡erences between high, moderate, and low levels of childbirth fear (Wilks’ l 5 17.7, po.001). Follow-up tests revealed that women with high childbirth fear were signi¢cantly more likely to have less help, more daily stressors, and more state anxiety and fatigue than those with moderate and low childbirth fear (see Table 3).
Parity, Childbirth Fear, Anxiety, and Sleep Deprivation When parity (nulliparous vs. multiparous women) was compared by MANOVA, the authors found di¡erences that were statistically signi¢cant (Wilks’
On the basis of hierarchical regression analysis, state anxiety was identi¢ed as the only independent variable predicting increased childbirth fear scores. Collinearity among predictor variables was examined; none were correlated at levels higher than .5. The regression model accounted for 28% of the variance in childbirth fear; all other statistically signi¢cant variables combined accounted for only 2% of the variance (see Table 4).
Discussion This exploratory descriptive study is the ¢rst of its kind to examine relationships among childbirth fear, sleep deprivation, fatigue, anxiety, and demographic factors. The proportions in this sample of Canadian women who reported high levels of fear (25%) were higher than a sample in Sweden (21.5%; Zar et al., 2001), similar to an Australian sample (26%; Fenwick, Gamble, Nathan, Bayes, & Hauck, 2009), and lower than a U.S. sample (52%; Lowe, 2000). The pattern of signi¢cant fear of childbirth as a common occurrence should cause concern, be addressed by practitioners, and be further explored by researchers. Unlike Finnish researchers, no di¡erence was found between nulliparous and multiparous women on levels of childbirth fear; however, Rouhe, Salmela-Aro, Halmesmki, and Saisto (2009) compared mean scores rather than grouping women on the basis of
Table 3: Follow-Up Comparison of Group Means for Levels of Childbirth Fear by MANOVA Variables
F Statistic
Significance
Low, Moderate, and High Group Means
Available help
12.705
po.001
6.43, 6.57, 5.55
Daily stressors
10.693
po.001
1.71, 1.81, 2.38
2.380
p 5 .093
456.71, 448.76, 435.73
Anxiety
85.756
po.001
30.04, 34.18, 43.32
Fatigue
26.596
po.001
25.599, 28.916, 33.124
Weekly sleep
Note. MANOVA 5 multivariate analysis of variance.
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JOGNN, 38, 567-576; 2009. DOI: 10.1111/j.1552-6909.2009.01054.x
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RESEARCH
Hall, W. A. et al.
Table 4: Summary of Hierarchical Multiple Regression Modeling for Variables Predicting Childbirth Fear Scores (n 5 624) p Variable
B
SEB
B
Value
Step 1 Age
0.281
0.188
.069
.136
Family income
0.478
0.535
.041
.372
Nulliparous versus
1.048
1.679
.026
.533
0.424
0.544
.35
.436
Age
0.13
0.162
.003
.936
Family income
0.989
0.461
.084
.032
Nulliparous versus
4.223
1.457
.106
.004
0.779
0.464
.063
.094
Fatigue (MAF)
0.172
0.084
.082
.042
Anxiety (STAI-S)
0.944
0.082
.494
o.001
Amount of sleep
0.001
0.008
.004
.904
0.053
0.520
.004
.919
0.336
0.321
.037
.295
multiparous Highest level of education Step 2
multiparous Highest level of education
(per week in min) Number of daily stressors Available help
Note. MAF 5 Multidimensional Assessment of Fatigue; STAI-S 5 Spielberger’s State Anxiety Inventory. R 2 5 .007 for step 1; DR 2 5 .28 for step 2 (pso.001).
their scores when they reported that nulliparous women were signi¢cantly more fearful than parous women. This ¢nding, which indicated that 21% of women were sleeping for less than 6 hours per night, is somewhat higher than Lee and Gay’s (2004) estimate of 15% by actigraphy. Actigraphy is considered a more objective measure of sleep than maternal report (Lee & Gay); therefore these ¢ndings, which were based on maternal report, may have overestimated sleep deprivation. Lee (2008) argued compellingly that sleep loss impairs function and has adverse health e¡ects. The correlations between the measures used in this study were interesting, because fatigue explained
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approximately 9% of the variance, while anxiety explained about 25%. The literature has consistently linked childbirth fear and anxiety but has not linked fatigue to childbirth fear. Andersson et al. (2004) related depressive or anxiety disorders during pregnancy to increased visits to care providers for childbirth fear. For women seeking counseling for childbirth fear, Ryding et al. (2007) found higher somatic anxiety scores and lower stress tolerance scores were associated with higher scores on the W-DEQ. Fatigue could account for lower stress tolerance. Finnish women’s fear of childbirth has been linked to increased general anxiety, high numbers of daily stressors, and lack of support, but fatigue was not measured (Saisto et al., 2001). Di⁄culties with making any general claims about relationships between state or trait anxiety and childbirth fear arise from lack of consistency in measures of anxiety in empirical work. In this study, state anxiety seems to represent a construct distinct from childbirth fear as the W-DEQ demonstrated convergent validity at a level of p 5 .54, which was consistent with Wijma’s ¢ndings (Wijma et al., 1998; see Table 2). The study ¢ndings about the relationship between fatigue and childbirth fear are important because the measures of fatigue and anxiety have very little overlap, except for one item, which asks about distress created by fatigue. Therefore, fatigue seems to be making a distinct contribution to childbirth fear. While many authors have presented fatigue as a common complaint during pregnancy (Chien & Ko, 2004; Lee & Gay, 2004; Pien & Schwab, 2004), its relationship with childbirth fear suggests clinicians cannot be complacent about fatigue during the last trimester of pregnancy, regardless of parity. Hours of sleep had a moderate inverse correlation with fatigue but did not make a signi¢cant contribution to di¡erences between high, moderate, and low childbirth fear or variance associated with childbirth fear scores. Previous work has suggested that total sleep time and number of wakes after sleep are moderately correlated with fatigue during labor and higher pain scores are associated with less total sleep time preceding labor (Beebe & Lee, 2007). The literature re£ects the complexity of relationships among fatigue, sleep, and elements of childbirth. The ¢nding that multiparous women experienced signi¢cantly more fatigue and anxiety, and fewer hours of sleep than nulliparous does not ¢t with those of Mindell and Jacobsen (2000), who reported no signi¢cant di¡erence between
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Health care providers need to consider approaches to prenatal care that devote equal attention to women’s physiological and psychological states.
multiparous and nulliparous women on any sleep indicators during pregnancy. On the other hand, the di¡erences between the groups were small and might not be viewed as being clinically meaningful. The small di¡erences in this group could be attributed to experiencing more demands with existing children and fewer opportunities for additional sleep hours. Higher levels of anxiety predicted higher childbirth fear scores in this study. Although the association between childbirth fear and anxiety is well-supported by other studies (Johnson & Slade, 2002; Ryding et al., 2007; Saisto et al., 2001), unlike the present study, those studies have not incorporated fatigue and sleep deprivation in their models. The large e¡ect size associated with anxiety outweighed contributions of any other variables to the variance associated with childbirth fear. Because the study was cross-sectional, it does not indicate the direction of relationships, and so it is not clear whether childbirth fear precedes anxiety and contributes to fatigue or if fatigue contributes to anxiety and childbirth fear. Further longitudinal research is necessary to untangle this complex web of relationships and develop explanatory theoretical models and approaches to prevention or treatment of childbirth fear. Linking women’s prenatal states to their birth outcomes will also contribute to explanatory models. In this sample, 25% had their primary care provided by a midwife, 38% by a family physician, and 36% by an obstetrician. The numbers of women receiving midwifery care in this sample are higher than the provincial norm of 8% in 2006/2007 (British Columbia Perinatal Health Program, 2008). The signi¢cant di¡erence in childbirth fear based on care provider may be because clients with lower levels of childbirth fear sought out midwives rather than referrals to obstetricians. On the other hand, in the study jurisdiction, family physicians who provide only antenatal care often refer low-risk women to obstetricians and recent research suggests their attitudes about risk and birth are very similar to those of obstetricians (Klein et al., in press). Thus, the di¡erence in childbirth fear could be due to the nature of the care received from the providers,
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what Fenwick et al. (2009) referred to as reassuring care by midwives.
Implications The authors found that women who have high childbirth fear were likely to have signi¢cantly less help available, more daily stressors, and more anxiety and fatigue than those with moderate or low childbirth fear. The authors suggest that health care providers could better support women during pregnancy by attending equally to their psychological, emotional, and physiological states. Some innovative approaches to prenatal care have been introduced such as Centering Pregnancy (Shindler-Rising, 1998), a group approach to prenatal care, which may provide women with opportunities to share their feelings and experiences, thus diminishing anxiety and feelings of fear. Australian women reported that supportive midwifery care and informal support networks reduced their childbirth fear (Fisher, Hauck, & Fenwick, 2006). In this study, fatigue and high numbers of daily stressors were correlated with childbirth fear. Because fatigue is regarded as a common problem in pregnancy, it can be di⁄cult to envisage interventions to reduce fatigue; however, these ¢ndings support the need for primary care providers and childbirth educators to spend more time with women and partners exploring fatigue levels and possible strategies to reduce fatigue. Increasing time spent discussing feelings of fatigue and sleep deprivation has the potential to validate women’s experiences and reduce their anxiety. Discussion of daily stressors and available help should also take priority. Reduction of daily stressors and increases in help could reduce anxiety, increase sleep, and reduce fatigue, which could be associated with reductions in childbirth fear. Further research that examines possible interventions for women who have been identi¢ed with high childbirth fear would be bene¢cial. A Finnish study reported that psychotherapeutic group sessions reduced women’s perceptions of childbirth fear (Saisto, Toivanen, Salmela-Aro, & Halmesmki, 2006). Women in the study indicated sharing their feelings during group sessions was most helpful in coping with their fear of birth. All of the women were requesting a Cesarean birth before group sessions, but 84% of women in the experimental group opted for vaginal birth by the end of the sessions. In the face of women’s high levels of fear of childbirth, more research is needed to investigate ways to engage in consciousness-raising around women’s inherent strengths to embrace birth.
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Limitations This sample overrepresented older, well-educated, women with partners in comparison with the large population-based Canadian Maternity Experiences Survey (Chalmers, Dzakpasu, Heaman, & Kaczorowski, 2008). Given that in 2006/2007 (British Columbia Perinatal Health Program, 2007), 46.6% of births in BC were to nulliparous women, this sample overrepresents nulliparous women in BC. These ¢ndings re£ect the limitations of sample of convenience. Women, for whom problems around fatigue, sleep deprivation, and childbirth fear were more salient, may have been more likely to participate; this study was limited by the inability to report on characteristics of women who were nonresponders to the survey, which increases the risk of nonresponse bias and the decision not to measure maternal depression. With the ordering of the questionnaire, women would have encountered the STAI-S before the W-DEQ, which would reduce the likelihood that responding to childbirth fear questions would in£uence their state anxiety; however, the women were free to alter their order of responses to the questions, and so it is possible that responding to childbirth fear questions ¢rst could have raised their anxiety levels. A psychometrically more robust measure of sleep would have strengthened the study ¢ndings.
Belza, B. L., Curtis, J. H., Yelin, E. H., Epstein, W. V., & Gilliss, C. L. (1993). Correlates of fatigue in older adults with rheumatoid arthritis. Nursing Research, 42(2), 93-99. Bowen, A., Bowen, R., Maslany, G., & Muhajarine, N. (2008). Anxiety in a socially high risk sample of women in Canada. Canadian Journal of Psychiatry, 53(7), 435-440. British Columbia Perinatal Health Program. (2007). British Columbia perinatal health database registry annual report. Vancouver, BC: Author. British Columbia Perinatal Health Program. (2008). Midwifery in British Columbia. Vancouver, BC: Author. Canadian Institute for Health Information. (2007) Analysis in brief: Giving birth in Canada: Regional trends from 2001-2002 to 2005-2006. Retrieved July 25, 2008, from http://secure.cihi.ca/cihiweb/disp Page.jsp?cw_page=AR_1106_E Canals, J., Esparo, G., & Fernandez-Ballart, J. D. (2002). How anxiety levels during pregnancy are linked to personality dimensions and sociodemographic factors. Personality and Individual Di¡erences, 33, 253-259. Chalmers, B., Dzakpasu, S., Heaman, M., & Kaczorowski, J. (2008). The Canadian maternity experiences survey: An overview of the ¢ndings. Journal of Obstetrics and Gynecology of Canada, 30(3), 217228. Chien, L., & Ko, Y. (2004). Fatigue during pregnancy predicts caesarean deliveries. Journal of Advanced Nursing, 45, 487-494. Fairbrother, N., Hutton, E. K., Stoll, K., Hall, W. A., & Kluka, S. (2008). Psychometric evaluation of the multidimensional assessment of fatigue scale for use with pregnant and postpartum women. Psychological Assessment, 20,150-158. Fairbrother, N., & Woody, S. R. (2007). Fear of childbirth and obstetric events as predictors of postnatal symptoms of depression and post-traumatic stress disorder. Journal of Psychosomatic Obstetrics and Gynecology, 28(4), 239-242.
Conclusion In conclusion, these ¢ndings suggest women’s fear of childbirth is related to fatigue, available support, stressors, and anxiety. Complex psychological states may be amenable to interventions to moderate their negative e¡ects. Understanding the signi¢cance of the direction of relationships among variables, such as childbirth fear, anxiety, and fatigue, will increase the likelihood that any such interventions are implemented successfully.
Fenwick, J., Gamble, J., Nathan, E., Bayes, S., & Hauck, Y. (2009). Pre-and post partum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. Journal of Clinical Nursing, 18(5), 667-677. Fisher, C., Hauck, Y., & Fenwick, J. (2006). How social context impacts women’s fears of childbirth. Social Science and Medicine, 63, 64-75. Geissbeuhler, E. J., & Eberhard, J. (2002). Fear of childbirth during pregnancy: A study of 8000 pregnant women. Journal of Psychosomatic Obstetrics and Gynecology, 23, 229-235. Hall, W. A., Clauson, M., Carty, E. M., Janssen, P., & Saunders, R. (2006). E¡ects on parents of an intervention to resolve infant behavioral sleep problems. Pediatric Nursing, 32, 243-250. Johnson, R. C., & Slade, P. (2002). Does fear of childbirth during pregnancy predict emergency caesarean section? British Journal of
Acknowledgments Funded by the British Columbia Medical Services Foundation and supported by research associates Kathy Gregg, Judy Bandsmer, and Cathy Ebbehoj.
Obstetrics and Gynaecology, 109, 1213-1221. Johnson, R. C., & Slade, P. (2003). Obstetric complications and anxiety during pregnancy: Is there a relationship? Journal of Psychosomatic Obstetrics and Gynecology, 24, 1-14. Klein, M., Kaczorowski, J., Hall, W. A., Fraser, W., Liston, R., Eftekhary, et al (in press). The attitudes of Canadian maternity care practitioners
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towards labour and birth: Di¡erences and similarities. Journal of Obstetrics and Gynecology of Canada. Laursen, M., Hedegaard, M., & Johansen, C. (2008). Fear of childbirth: Predictors and temporal changes among nulliparous women in the Danish National Birth Cohort. British Journal of Obstetrics and Gynaecology, 15(3), 354-360. Lee, K. A. (2008). In search of sleep: It’s a family a¡air. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(6), 705.
e¡ects of childbirth self-e⁄cacy and anxiety during pregnancy on
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Lowe, N. K. (2000). Self-e⁄cacy for labor and childbirth fears in nullipa-
Saisto, T., Salmela-Aro, K., Nurmi, J., & Halmesmki, E. (2001). Psychoso-
rous pregnant women. Journal of Psychosomatic Obstetrics and
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childbirth. British Journal of Obstetrics and Gynaecology, 108(5),
Mindell, J. A., & Jacobsen, B. J. (2000). Sleep disturbances during pregnancy. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 29, 590-597. Pien, G. W., & Schwab, R. J. (2004). Sleep disorders during pregnancy. Sleep, 27, 1405-1417. Rouhe, H., Salmela-Aro, K., Halmesmki, E., & Saisto, T. (2009). Fear of childbirth according to parity, gestational age, and obstetric history. BJOG: An International Journal of Obstetrics and Gynaecology, 116, 67-73. Ryding, E. L., Wijma, B., Wijma, K., & Rydhstr˛m, H. (1998). Fear of childbirth during pregnancy may increase the risk of Cesarean section. Acta Obstetricia et Gynecologica Scandinavica, 77(5), 542-547.
peutic group psychoeducation and relaxation in treating fear of childbirth. Acta Obstreticia et Gynecologica, 85, 1315-1319. Shindler-Rising, S. (1998). Centering Pregnancy: An interdisciplinary model of empowerment. Journal of Nurse-Midwifery, 43, 46-54. Spielberger, C. D., Gorsuch, R. L., & Lushene, L. E. (1983). Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press. Waldenstr˛m, U., Hildingsson, I., & Ryding, E. L. (2006). Antenatal fear of childbirth and its association with subsequent Cesarean section and experience of childbirth. British Journal of Obstetrics and Gynaecology, 113, 638-646.
Ryding, E. L., Wir¢eld, E., Wngborg, I. B., Sj˛ergn, B., & Edman, G. (2007).
Wijma, K., Wijma, B., & Zar, M. (1998). Psychometric aspects of the W-DEQ;
Personality and fear of childbirth. Acta Obstericia et Gynecologica
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Scandinavica, 86, 814-820. Saisto, T., & Halmesmki, E. (2003). Fear of childbirth: A neglected di-
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JOGNN, 38, 567-576; 2009. DOI: 10.1111/j.1552-6909.2009.01054.x
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Childbirth Fear, Anxiety, Fatigue, and Sleep Deprivation in Pregnant Women Wendy A. Hall, Yvonne L. Hauck, Elaine M. Carty, Eileen K. Hutton, Jennifer Fenwick, and Kathrin Stoll
Correspondence Wendy A. Hall, T. 201, 2211, University of British Columbia School of Nursing, Wesbrook Mall, Vancouver, British Columbia, Canada V6T 2B5. [email protected] Keywords childbirth fear anxiety fatigue sleep deprivation pregnancy
ABSTRACT Objective: To explore women’s levels of childbirth fear, sleep deprivation, anxiety, and fatigue and their relationships during the third trimester of pregnancy. Design: A cross-sectional descriptive survey of a community sample. Participants: Six hundred and fifty English-speaking nulliparous and multiparous women, 17 to 46 years of age and between 35 and 39 weeks gestation, with uncomplicated pregnancies. Methods: Wijma Delivery Expectancy/Experience Questionnaire, Spielberger State Anxiety Mindell’s Sleep Questionnaire, and the Multidimensional Assessment of Fatigue Questionnaire.
Inventory,
Results: Twenty-five percent of women reported high levels of childbirth fear and 20.6% reported sleeping less than 6 hours per night. Childbirth fear, fatigue, sleep deprivation, and anxiety were positively correlated. Fewer women attending midwives reported severe fear of childbirth than those attending obstetricians. Women with high childbirth fear were more likely to have more daily stressors, anxiety, and fatigue, as well as less help. Higher levels of anxiety predicted higher levels of childbirth fear among women. Conclusion: One fourth of women reported high childbirth fear. Women’s fear of childbirth was related to fatigue, available help, stressors, and anxiety. Fear of childbirth appears to be part of a complex picture of women’s emotional experiences during pregnancy.
JOGNN, 38, 567-576; 2009. DOI: 10.1111/j.1552-6909.2009.01054.x Accepted July 2009
s rates of Cesarean deliveries increase around the world, researchers and clinicians contemplate possible explanations. For example, rates of childbirth interventions are steadily increasing in Canada, with a national Cesarean birth rate of 26% (Canadian Institute for Health Information, 2007). Psychological factors, such as fear and anxiety around the childbirth process (Andersson, Sundstrom-Poromaa, Wul¡, —str˛m, & Bixo, 2004; Ryding, Wijma, Wijma, & Rydhstr˛m, 1998; Saisto & Halmesmki, 2003), sleep deprivation, or fatigue (Chien & Ko, 2004; Lee & Gay, 2004) have been implicated in increased childbirth interventions. Although each of these factors has been examined in relation to childbirth outcomes, relationships among childbirth fear, anxiety, sleep deprivation, and fatigue have not been studied, and combined contributions of these variables have not been examined in relation to birth outcomes.
A Wendy A. Hall, PhD, RN, is a professor at the University of British Columbia School of Nursing, Vancouver, British Columbia, Canada. Yvonne. L. Hauck, PhD, RM, RN, is a professor in the School of Population Health, University of Western Australia, Perth, Western Australia. Elaine M. Carty, MN, RN, is a professor emeritus, at the University of British Columbia School of Nursing, Vancouver, British Columbia, Canada. (Continued)
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The purpose of the study was to examine relationships among women’s childbirth fear, sleep deprivation, fatigue, and state anxiety in a sample of 650 pregnant women in the province of British Columbia (BC). The variables for the ¢rst phase of the study were identi¢ed to enable prospective examination of e¡ects of childbirth fear, anxiety, sleep deprivation, and fatigue on childbirth outcomes. A second phase of the study is currently underway where the birth records of the study participants are being obtained to provide data on birth outcomes. Fear of childbirth has been attributed to fear of pain, psychological factors, such as fear of future parenthood, and social factors, such as lack of support (Saisto & Halmesmki, 2003). Wijma, Wijma, and Zar (1998) argued that fear of childbirth occupies a domain separate from anxiety and arises from women’s expectancies and appraisals of speci¢c
& 2009 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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This study examined relationships among women’s childbirth fear, sleep deprivation, fatigue, and state anxiety. childbirth experiences. In support of their argument, in a small sample of pregnant women, trait anxiety correlated with childbirth self-e⁄cacy and the total score for a measure of pregnancy and childbirth-related anxiety but did not correlate speci¢cally with a subscale measuring pain, fear, and loss of control during labor (Beebe, Lee, Carrieri-Kohlman, & Humphreys, 2007). Factors associated with childbirth fear have included young maternal age, low education, lack of social support, high numbers of daily stressors, dissatisfaction with partner relationships, unemployment, smoking, poor self-rated health, and anxiety (Laursen, Hedegaard, & Johansen, 2008; Saisto & Halmesmki; Saisto, SalmelaAro, Nurmi, & Halmesmki, 2001). Childbirth fear has been studied in many countries with di¡erent ¢ndings. For example, the incidence of childbirth fear has been reported at 52% in a sample of 280 women in the United States (Lowe, 2000), 10% in a sample of 2,662 Finnish women (Waldenstr˛m, Hildingsson, & Ryding, 2006), and 5% in a sample of 8,000 Swiss women (Geissbeuhler & Eberhard, 2002). These di¡erences could be attributed to cultural factors or to the use of di¡erent measures in studies. For example, the Swiss study used a single question to ask about levels of fear of childbirth, whereas the American study used a modi¢ed fear of childbirth questionnaire with cut-o¡ scores for high and low childbirth fear. Zar, Wijma, and Wijma (2001) reported 20% of women in developed countries, such as Sweden and Australia, experience childbirth fear. Eileen K. Hutton, PhD, RN, is an associate professor of obstetrics and gynecology and assistant dean in the Midwifery Education Program, McMaster University, Hamilton, Ontario, Canada. Jennifer Fenwick, PhD, RM, RN, is an associate professor, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Australia. Kathrin Stoll, is a PhD student in interdisciplinary studies at the University of British Columbia.
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An association between anxiety and fear of childbirth has been reported by several authors (Andersson et al., 2004; Fairbrother & Woody, 2007; Johnson & Slade, 2003; Ryding et al., 1998). State anxiety captures anxiety at a given point in time, whereas trait anxiety refers to a stable personality trait (Spielberger, Gorsuch, & Lushene, 1983). The State Anxiety Measure has been used in several studies of pregnancy with di¡ering results. For example, a study by Canals, Esparo, and FernandezBallart (2002) identi¢ed no signi¢cant di¡erences in state anxiety between nulliparous and multiparous women during the last 3 months of pregnancy. In a study of socially high-risk pregnant women, state anxiety was associated with younger maternal age and stressors such as being pregnant, worry about money, and concern about
infant health (Bowen, Bowen, Maslany, & Muhajarine, 2008); these factors have also been related to childbirth fear. In terms of birth outcomes, state anxiety has been associated with an increased risk for planned Cesarean birth and length of labor (Andersson et al.). Johnson and Slade conducted an extensive review of anxiety and obstetric complications and concluded that fear of childbirth is a distinct dimension of anxiety that has implications for the delivery experience. Although sleep deprivation and fatigue during pregnancy have separately been associated with increased risk of obstetric interventions (Chien & Ko, 2004; Lee & Gay, 2004), no studies have examined these variables in relation to childbirth fear. Common sleep problems of the third trimester of pregnancy, such as nocturnal waking to void, di⁄culty getting comfortable, heartburn, and restless sleep due to fetal movement (Pien & Schwab, 2004) as well as conditions such as restless leg syndrome and obstructive sleep apnea (Mindell & Jacobsen, 2000;Pien & Schwab) lead to disrupted sleep and reduced energy levels (Beebe & Lee, 2007). Beebe and Lee reported more night waking was positively associated with response to pain and fatigue scores in a small sample of women in early labor. Moreover, fatigue levels during pregnancy have predicted Cesarean delivery (Chien & Ko), and sleep deprivation in late pregnancy (less than 6 hours per night) has increased women’s rates of Cesarean birth threefold compared with women without sleep deprivation (Lee & Gay). Links between childbirth fear, birth interventions, and other psychological factors, such as personality characteristics and sociodemographic factors, have been studied, but the relationships among childbirth fear and other contributing factors to birth interventions, such as fatigue and sleep deprivation, are not yet fully understood. The purpose of the ¢rst phase of this study was to describe the characteristics of 650 pregnant women, 35 to 39 weeks gestation, with respect to sleep, anxiety, fatigue, and childbirth fear. Speci¢c aims were to 1. describe women’s levels of childbirth fear; 2. describe women’s sleep deprivation; 3. examine relationships among levels of childbirth fear and sleep, anxiety, fatigue, and contextual factors, with the goal of identifying predictors of childbirth fear; and 4. examine similarities and di¡erences in nulliparous and multiparous women in terms of childbirth fear, sleep deprivation, anxiety, and fatigue.
JOGNN, 38, 567-576; 2009. DOI: 10.1111/j.1552-6909.2009.01054.x
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Hall, W. A. et al.
Methods Design The study was a cross-sectional descriptive survey design.
Sample and Setting Women were recruited between May 2005 and July 2007 from communities across the province of BC that had 150 births or more annually. The community inclusion criterion was based on the estimated cost of sending materials to a community. The convenience sample included pregnant women who resided in BC at the time of data collection, could speak and read English, and were between 35 and 39 weeks gestation. Women who were experiencing high-risk conditions associated with their pregnancies (e.g., pregnancy-induced hypertension, preterm labor, bleeding, and type 1 diabetes), had a diagnosed sleep disorder, or worked continuous night shifts were excluded from the study. Women who contacted the study coordinator before the eligible gestational age were put on a wait list and contacted immediately before 35 weeks gestation to ascertain whether they were still interested in participating. A power calculation indicated that assuming medium e¡ect sizes and a 5 .05, a sample size of 150 would provide power (in excess of .85) for analysis of variance (ANOVA). The overall sample size exceeded the one determined by the power calculation for examining relationships among the variables to ensure an adequate sample would be available for the second phase of the study, which is intended to determine how the variables contributed prospectively to a number of birth outcomes.
Procedures The study was reviewed and approved by the University of British Columbia Ethical Review Board and BC Women’s and Children’s Hospital Ethics Committee. Study information was sent to care providers’ o⁄ces, antenatal education classes, online pregnancy and parenting resource sites, large companies, such as telephone and hydro companies, and provincial unions. Print media were also placed in maternity and children’s toy stores. Researchers attended community events for pregnant women and provided interviews about the study for radio, television, and newspapers. After receiving information from the study coordinator and consenting to participate, women were sent a package that included a consent form to provide permission to access their birth records (for followup study), demographic questions developed for
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this study, and standardized measurement tools including the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ, childbirth fear; Wijma et al., 1998), Spielberger’s State Anxiety Inventory (STAI-S; Spielberger et al., 1983), Mindell’s Sleep Questionnaire (Mindell & Jacobsen, 2000), and the Multidimensional Assessment of Fatigue (MAF scale; Belza, Curtis, Yelin, Epstein, & Gilliss, 1993). Questionnaires were returned by mail within a week or two of receiptçbefore the women gave birth. If questionnaires were not returned within 2 weeks, participants received reminder e-mails or phone calls on two occasions 2 weeks apart from the study coordinator to encourage them to return their questionnaires.
Measures Demographic data included maternal date of birth, personal health number, presence of a partner in the home, ethnicity, number of previous pregnancies, number of living children and their ages, geographic location, education level, family income, current employment status, a single item about help (number of people available for help), number and type of daily stressors (relationships, employment, ¢nances, education, and health), questions about previous adverse labor and birth experiences, type of primary care provider, a single item about attendance at childbirth education classes, and a single item for intentions regarding Cesarean birth and other birth-related interventions. The demographic form was developed by the investigators. The W-DEQ is a 33-item questionnaire that measures fear of childbirth on a 6-point likert scale using expectations about experiences during labor and birth (Zar et al., 2001). Scores equal to or lower than 37 indicate low fear, 38 to 65 indicate moderate fear, and equal to or higher than 66 represent high levels of fear. The internal consistency and split-half reliability of the W-DEQ has been high: greater than .94 in both nulliparous and multiparous women; the W-DEQ had support for construct validity, because it overlapped by 30% with trait anxiety in a sample of nulliparous and multiparous women, and in multiparous women, correlated highly with other measures of childbirth fear (r 5 .65-.78; Wijma et al.,1998). There is also evidence of its predictive validity, as pregnant women with intense fear of childbirth had a more negative perception of their births 1 week postbirth (Ryding, Wir¢eld, Wngborg, Sj˛ergn, & Edman, 2007). The STAI-S is one of the most widely used measures of subjective anxiety (Spielberger et al., 1983). The
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State inventory consists of 20 items that measure the anxiety at a given point in time, with the lowest score at 20 and the highest score at 80. The measure has extensive support for validity and reliability in the childbearing population, with internal consistencies as high as .92 (Canals et al., 2002). The choice of the STAI-S ¢ts with a review of obstetric complications and anxiety wherein Johnson and Slade (2003) argued that trait anxiety is unrelated to obstetric complications. Another study, where the correlation of the STAI-T with childbirth fear was at r 5 .05 (Johnson & Slade, 2002), also suggests anxiety represents a di¡erent construct than childbirth fear. Mindell’s Sleep Questionnaire was used to determine sleep deprivation (Mindell & Jacobsen, 2000). The questionnaire is speci¢cally designed for pregnant women and requests information about sleep patterns and disruptions during the previous 2 weeks. The instrument provides similar data to sleep diaries without requesting women to record their nighttime activities for several days. Cronbach’s as for the measure were reported at .52 for sleep patterns and .76 for sleep disordered breathing (Mindell & Jacobsen). No information was provided about the validity of the measure. The MAF scale is an instrument that measures fatigue severity, distress, degree of interference in activities of daily living, and timing (Belza et al., 1993). The preceding subscales combine to give a total fatigue score, with high scores equaling high levels of fatigue. In other studies of childbearing women, the measure has demonstrated high internal validity (a 5 .93-.96), sensitivity to changes in fatigue from pregnancy to 2 weeks postpartum, using one-way repeated-measures ANOVA, F(1,113) 5 25.66, po.001, and pre- and postsleep intervention, t(2, 69) 5 4.4, po.001 (Fairbrother, Hutton, Stoll, Hall, & Kluka, 2008; Hall, Clauson, Carty, Janssen, & Saunders, 2006), and convergent validity with the Pittsburgh Sleep Quality Index (r 5 .48-.64, po.001); it is considered valid for use in the pregnant population (Fairbrother et al.).
Analysis Statistical Package for the Social Sciences 16.0 was used for all statistical analyses. Interval data were summarized using means, standard deviations (SDs), medians, and interquartile ranges. Categorical data were summarized using frequency distributions. On the basis of scores on the W-DEQ, women were placed into high, moderate, or low childbirth fear groups by using fourth quartile scores that indicated high levels of fear (greater
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than or equal to 66), second and third quartile scores that indicated moderate levels of fear (3865), and ¢rst quartile scores that indicated low levels of childbirth fear (less than 37). Women were categorized as sleep deprived (less than 6 hours) versus non^sleep-deprived (greater than or equal to 6 hours) based on their average hours of night sleep calculated from the Mindell Sleep measure. The authors used cut-o¡ scores on the Mindell scale based on those used by Lee and Gay (2004), because they reported less than 6 hours of sleep per night increased the risk of Cesarean deliveries. The authors also calculated the proportions of women with interrupted sleep who were up three or more times per night (de¢ned as sleep fragmentation). For all analysis testing, a p value of .05 was accepted as signi¢cant. Pearson’s correlation coe⁄cients were calculated for childbirth fear, state anxiety, fatigue, and hours of sleep per night. Groups based on high, moderate, and low levels of childbirth fear were compared on number of stressors, number of people available for help, fatigue, sleep hours per week, and anxiety using a oneway multivariate analysis of variance (MANOVA). Chi-square analyses were used to compare groups on categorical variables, such as the care provider. Finally, hierarchical regression modeling was used to examine potential predictors of level of childbirth fear. Possible predictors included age, educational level, family income, parity, amount of sleep per week, available help, state anxiety, fatigue, and number of daily stressors. The selection of psychosocial predictor variables was based on the results of the bivariate analyses that indicated an association between a given predictor and childbirth fear. Sociodemographic predictor variables were selected on the basis of previous research.
Results Nine hundred and sixteen ¢rst-time and previously pregnant women responded to the recruitment techniques. Thirty women on the waitlist did not reach 35 weeks during their pregnancies by the time recruitment was suspended because the minimum sample size was exceeded based on power analysis and the funding ended. Twelve women became ineligible during their time on the waitlist for health reasons and two moved out of province. The authors were unable to contact 30 women. Two decided not to participate. A sample of 872 agreed to complete questionnaires, with 650 surveys returned with usable data (75%). The women who responded to the survey were on average 31.5 years old, predominantly Canadian
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Hall, W. A. et al.
(69%), and well educated (over 50% had completed a university degree; see Table 1). Sixty percent were nulliparous and 40% were multiparous. Fiftytwo percent of the multiparous women described having di⁄cult labors with previous pregnancies. Approximately 25% of the sample had midwives as their primary care provider while 36% were seeing an obstetrician and 39% a family physician (see Table 1 for additional sample characteristics). In BC, under the medical services plan, women are able to choose a midwife or family physician as a primary care provider. An obstetrician becomes a primary care provider only on referral; however, family physicians who do not provide intrapartum care often refer low-risk women to obstetricians late in pregnancy. When the authors compared women by childbirth fear group and care provider the chisquare statistic was signi¢cant, w2 (4) 5 24.0, po .001, with 16% of midwifery clients in the high-fear group versus 35% of obstetricians’ clients. Seventy percent of the sample reported 1 to 3 daily stressors and 13% reported four or more. Moreover, 35% of the women reported relationships as a stressor and 51% reported ¢nances as a stressor. Of the women who did not have a previous Cesarean delivery, 4% planned to request Cesarean birth. Findings from the bivariate and multivariate analyses are organized according to the stated purposes of the study.
Characteristics of the Measures In this study, the mean for the W-DEQ was 52.87 (SD 5 19.66) and Cronbach’s a was .92. For the STAI-S, the mean was 35.56, with a SD of 10.33 and a Cronbach’s a of .93. For Mindell’s Sleep Questionnaire, a Cronbach’s alpha was not calculated because the authors used single items such as number of hours of sleep per night and number of waking times per night as variables of interest. For the MAF scale, the mean for the scale was 29.26 (SD 5 9.34) and the Cronbach’s a was .93. The ordering of the scales in the questionnaire was the STAI-S, W-DEQ, MAF, and Mindell’s Sleep Questionnaire.
Women’s Levels of Childbirth Fear Twenty-¢ve percent of the sample reported high levels of fear (n 5 162), while 54% reported moderate fear (n 5 349), and 21% low levels of childbirth fear (n 5 138).
Twenty-five percent of the sample reported high levels of childbirth fear, with 54% reporting moderate fear and only 21% low levels of fear.
Table 1: Demographic Characteristics of Sample Characteristics, Range (Mean) [Median] Age (years), 17-46 (31.5) [32] o25
8.5 (55)
25-35
70.7 (459)
435
20.8 (135)
Number of children, 0-4 (0.5) [0] None
59.7 (388)
One child
31.7 (206)
More than one child
By the de¢nition of a cut-o¡ score of less than 6 hours of sleep per night, 21% (n 5 134) of the sample reported being sleep deprived. Approximately 68% of the women (n 5 440) in this study
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8.6 (56)
Partner Yes
98.2 (638)
No
1.8 (12)
Education High school or less
8.8 (57)
College or less
28 (182)
University degree or less
45 (292)
Postgraduate degree
18.2 (118)
Family income o$20,000
2.7 (17)
$20,000-39,000
10.6 (67)
$40,000-59,000
17.3 (109)
$60,000-79,000
16.6 (105)
$80,000-99,000
19.8 (125)
4$100,000 Characteristics
33 (207) Percentages (n)
Ethnicity (self-identi¢ed) Aboriginal
2 (12)
African/Caribbean
2 (9)
Asian/Chinese
Women’s Sleep Deprivation
Percentages (n)
7.6 (49)
Canadian
69.4 (450)
European
12.6 (81)
Latin
1.5 (7)
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Table 2: Correlation Coefficients Among Primary Variables
Variables
Childbirth
Sleep Hours
Fear
per Night
Anxiety
Childbirth Fear Sleep Hours per Night
.12
Anxiety
.54
.22
Fatigue
.31
.22
.49
Note. po.001.
l 5 8.1, po.001). Follow-up tests revealed that multiparous women had signi¢cantly higher levels of fatigue (MAF score 5 31.3 vs. 27.9 for nulliparous), fewer hours of sleep (7.6 vs. 7.3), and more feelings of state anxiety (STAI-S 5 36.9 vs. 34.7); however, these di¡erences might not be large enough to be clinically meaningful. Moreover, there were no signi¢cant di¡erences between nulliparous and multiparous on sleep deprivation as indicated by a cut-o¡ score of less than 6 hours per night (p4.25).
Predictors of Childbirth Fear
indicated that they got up three or more times per night, which was de¢ned as sleep fragmentation.
Associations among childbirth fear, anxiety, sleep deprivation, fatigue, state anxiety, daily stressors, and available help The authors examined relationships among childbirth fear, sleep deprivation, state anxiety, and fatigue. All of the variables were signi¢cantly correlated with childbirth fear, though only state anxiety and fatigue displayed moderate to strong correlations (see Table 2). In addition, the MANOVA revealed signi¢cant di¡erences between high, moderate, and low levels of childbirth fear (Wilks’ l 5 17.7, po.001). Follow-up tests revealed that women with high childbirth fear were signi¢cantly more likely to have less help, more daily stressors, and more state anxiety and fatigue than those with moderate and low childbirth fear (see Table 3).
Parity, Childbirth Fear, Anxiety, and Sleep Deprivation When parity (nulliparous vs. multiparous women) was compared by MANOVA, the authors found di¡erences that were statistically signi¢cant (Wilks’
On the basis of hierarchical regression analysis, state anxiety was identi¢ed as the only independent variable predicting increased childbirth fear scores. Collinearity among predictor variables was examined; none were correlated at levels higher than .5. The regression model accounted for 28% of the variance in childbirth fear; all other statistically signi¢cant variables combined accounted for only 2% of the variance (see Table 4).
Discussion This exploratory descriptive study is the ¢rst of its kind to examine relationships among childbirth fear, sleep deprivation, fatigue, anxiety, and demographic factors. The proportions in this sample of Canadian women who reported high levels of fear (25%) were higher than a sample in Sweden (21.5%; Zar et al., 2001), similar to an Australian sample (26%; Fenwick, Gamble, Nathan, Bayes, & Hauck, 2009), and lower than a U.S. sample (52%; Lowe, 2000). The pattern of signi¢cant fear of childbirth as a common occurrence should cause concern, be addressed by practitioners, and be further explored by researchers. Unlike Finnish researchers, no di¡erence was found between nulliparous and multiparous women on levels of childbirth fear; however, Rouhe, Salmela-Aro, Halmesmki, and Saisto (2009) compared mean scores rather than grouping women on the basis of
Table 3: Follow-Up Comparison of Group Means for Levels of Childbirth Fear by MANOVA Variables
F Statistic
Significance
Low, Moderate, and High Group Means
Available help
12.705
po.001
6.43, 6.57, 5.55
Daily stressors
10.693
po.001
1.71, 1.81, 2.38
2.380
p 5 .093
456.71, 448.76, 435.73
Anxiety
85.756
po.001
30.04, 34.18, 43.32
Fatigue
26.596
po.001
25.599, 28.916, 33.124
Weekly sleep
Note. MANOVA 5 multivariate analysis of variance.
572
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RESEARCH
Hall, W. A. et al.
Table 4: Summary of Hierarchical Multiple Regression Modeling for Variables Predicting Childbirth Fear Scores (n 5 624) p Variable
B
SEB
B
Value
Step 1 Age
0.281
0.188
.069
.136
Family income
0.478
0.535
.041
.372
Nulliparous versus
1.048
1.679
.026
.533
0.424
0.544
.35
.436
Age
0.13
0.162
.003
.936
Family income
0.989
0.461
.084
.032
Nulliparous versus
4.223
1.457
.106
.004
0.779
0.464
.063
.094
Fatigue (MAF)
0.172
0.084
.082
.042
Anxiety (STAI-S)
0.944
0.082
.494
o.001
Amount of sleep
0.001
0.008
.004
.904
0.053
0.520
.004
.919
0.336
0.321
.037
.295
multiparous Highest level of education Step 2
multiparous Highest level of education
(per week in min) Number of daily stressors Available help
Note. MAF 5 Multidimensional Assessment of Fatigue; STAI-S 5 Spielberger’s State Anxiety Inventory. R 2 5 .007 for step 1; DR 2 5 .28 for step 2 (pso.001).
their scores when they reported that nulliparous women were signi¢cantly more fearful than parous women. This ¢nding, which indicated that 21% of women were sleeping for less than 6 hours per night, is somewhat higher than Lee and Gay’s (2004) estimate of 15% by actigraphy. Actigraphy is considered a more objective measure of sleep than maternal report (Lee & Gay); therefore these ¢ndings, which were based on maternal report, may have overestimated sleep deprivation. Lee (2008) argued compellingly that sleep loss impairs function and has adverse health e¡ects. The correlations between the measures used in this study were interesting, because fatigue explained
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approximately 9% of the variance, while anxiety explained about 25%. The literature has consistently linked childbirth fear and anxiety but has not linked fatigue to childbirth fear. Andersson et al. (2004) related depressive or anxiety disorders during pregnancy to increased visits to care providers for childbirth fear. For women seeking counseling for childbirth fear, Ryding et al. (2007) found higher somatic anxiety scores and lower stress tolerance scores were associated with higher scores on the W-DEQ. Fatigue could account for lower stress tolerance. Finnish women’s fear of childbirth has been linked to increased general anxiety, high numbers of daily stressors, and lack of support, but fatigue was not measured (Saisto et al., 2001). Di⁄culties with making any general claims about relationships between state or trait anxiety and childbirth fear arise from lack of consistency in measures of anxiety in empirical work. In this study, state anxiety seems to represent a construct distinct from childbirth fear as the W-DEQ demonstrated convergent validity at a level of p 5 .54, which was consistent with Wijma’s ¢ndings (Wijma et al., 1998; see Table 2). The study ¢ndings about the relationship between fatigue and childbirth fear are important because the measures of fatigue and anxiety have very little overlap, except for one item, which asks about distress created by fatigue. Therefore, fatigue seems to be making a distinct contribution to childbirth fear. While many authors have presented fatigue as a common complaint during pregnancy (Chien & Ko, 2004; Lee & Gay, 2004; Pien & Schwab, 2004), its relationship with childbirth fear suggests clinicians cannot be complacent about fatigue during the last trimester of pregnancy, regardless of parity. Hours of sleep had a moderate inverse correlation with fatigue but did not make a signi¢cant contribution to di¡erences between high, moderate, and low childbirth fear or variance associated with childbirth fear scores. Previous work has suggested that total sleep time and number of wakes after sleep are moderately correlated with fatigue during labor and higher pain scores are associated with less total sleep time preceding labor (Beebe & Lee, 2007). The literature re£ects the complexity of relationships among fatigue, sleep, and elements of childbirth. The ¢nding that multiparous women experienced signi¢cantly more fatigue and anxiety, and fewer hours of sleep than nulliparous does not ¢t with those of Mindell and Jacobsen (2000), who reported no signi¢cant di¡erence between
573
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Childbirth Fear
Health care providers need to consider approaches to prenatal care that devote equal attention to women’s physiological and psychological states.
multiparous and nulliparous women on any sleep indicators during pregnancy. On the other hand, the di¡erences between the groups were small and might not be viewed as being clinically meaningful. The small di¡erences in this group could be attributed to experiencing more demands with existing children and fewer opportunities for additional sleep hours. Higher levels of anxiety predicted higher childbirth fear scores in this study. Although the association between childbirth fear and anxiety is well-supported by other studies (Johnson & Slade, 2002; Ryding et al., 2007; Saisto et al., 2001), unlike the present study, those studies have not incorporated fatigue and sleep deprivation in their models. The large e¡ect size associated with anxiety outweighed contributions of any other variables to the variance associated with childbirth fear. Because the study was cross-sectional, it does not indicate the direction of relationships, and so it is not clear whether childbirth fear precedes anxiety and contributes to fatigue or if fatigue contributes to anxiety and childbirth fear. Further longitudinal research is necessary to untangle this complex web of relationships and develop explanatory theoretical models and approaches to prevention or treatment of childbirth fear. Linking women’s prenatal states to their birth outcomes will also contribute to explanatory models. In this sample, 25% had their primary care provided by a midwife, 38% by a family physician, and 36% by an obstetrician. The numbers of women receiving midwifery care in this sample are higher than the provincial norm of 8% in 2006/2007 (British Columbia Perinatal Health Program, 2008). The signi¢cant di¡erence in childbirth fear based on care provider may be because clients with lower levels of childbirth fear sought out midwives rather than referrals to obstetricians. On the other hand, in the study jurisdiction, family physicians who provide only antenatal care often refer low-risk women to obstetricians and recent research suggests their attitudes about risk and birth are very similar to those of obstetricians (Klein et al., in press). Thus, the di¡erence in childbirth fear could be due to the nature of the care received from the providers,
574
what Fenwick et al. (2009) referred to as reassuring care by midwives.
Implications The authors found that women who have high childbirth fear were likely to have signi¢cantly less help available, more daily stressors, and more anxiety and fatigue than those with moderate or low childbirth fear. The authors suggest that health care providers could better support women during pregnancy by attending equally to their psychological, emotional, and physiological states. Some innovative approaches to prenatal care have been introduced such as Centering Pregnancy (Shindler-Rising, 1998), a group approach to prenatal care, which may provide women with opportunities to share their feelings and experiences, thus diminishing anxiety and feelings of fear. Australian women reported that supportive midwifery care and informal support networks reduced their childbirth fear (Fisher, Hauck, & Fenwick, 2006). In this study, fatigue and high numbers of daily stressors were correlated with childbirth fear. Because fatigue is regarded as a common problem in pregnancy, it can be di⁄cult to envisage interventions to reduce fatigue; however, these ¢ndings support the need for primary care providers and childbirth educators to spend more time with women and partners exploring fatigue levels and possible strategies to reduce fatigue. Increasing time spent discussing feelings of fatigue and sleep deprivation has the potential to validate women’s experiences and reduce their anxiety. Discussion of daily stressors and available help should also take priority. Reduction of daily stressors and increases in help could reduce anxiety, increase sleep, and reduce fatigue, which could be associated with reductions in childbirth fear. Further research that examines possible interventions for women who have been identi¢ed with high childbirth fear would be bene¢cial. A Finnish study reported that psychotherapeutic group sessions reduced women’s perceptions of childbirth fear (Saisto, Toivanen, Salmela-Aro, & Halmesmki, 2006). Women in the study indicated sharing their feelings during group sessions was most helpful in coping with their fear of birth. All of the women were requesting a Cesarean birth before group sessions, but 84% of women in the experimental group opted for vaginal birth by the end of the sessions. In the face of women’s high levels of fear of childbirth, more research is needed to investigate ways to engage in consciousness-raising around women’s inherent strengths to embrace birth.
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RESEARCH
Hall, W. A. et al.
Limitations This sample overrepresented older, well-educated, women with partners in comparison with the large population-based Canadian Maternity Experiences Survey (Chalmers, Dzakpasu, Heaman, & Kaczorowski, 2008). Given that in 2006/2007 (British Columbia Perinatal Health Program, 2007), 46.6% of births in BC were to nulliparous women, this sample overrepresents nulliparous women in BC. These ¢ndings re£ect the limitations of sample of convenience. Women, for whom problems around fatigue, sleep deprivation, and childbirth fear were more salient, may have been more likely to participate; this study was limited by the inability to report on characteristics of women who were nonresponders to the survey, which increases the risk of nonresponse bias and the decision not to measure maternal depression. With the ordering of the questionnaire, women would have encountered the STAI-S before the W-DEQ, which would reduce the likelihood that responding to childbirth fear questions would in£uence their state anxiety; however, the women were free to alter their order of responses to the questions, and so it is possible that responding to childbirth fear questions ¢rst could have raised their anxiety levels. A psychometrically more robust measure of sleep would have strengthened the study ¢ndings.
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Conclusion In conclusion, these ¢ndings suggest women’s fear of childbirth is related to fatigue, available support, stressors, and anxiety. Complex psychological states may be amenable to interventions to moderate their negative e¡ects. Understanding the signi¢cance of the direction of relationships among variables, such as childbirth fear, anxiety, and fatigue, will increase the likelihood that any such interventions are implemented successfully.
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Acknowledgments Funded by the British Columbia Medical Services Foundation and supported by research associates Kathy Gregg, Judy Bandsmer, and Cathy Ebbehoj.
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JOGNN, 38, 567-576; 2009. DOI: 10.1111/j.1552-6909.2009.01054.x
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