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Fears associated with childbirth among nulliparous women in Turkey
ARTICLE IN PRESS Midwifery (2009) 25, 155–162
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Fears associated with childbirth among nulliparous women in Turkey Pınar Serc-ekus- , MSc, RN (Research Assistant), Hu ¨lya Okumus-, Phd, RN (Professor) ´nciralty´, Y ´ZMY ´R 35340 Turkey Dokuz Eylu ¨ l University School of Nursing, Mithatpaba Street, Y
Corresponding author.
E-mail addresses: [email protected] (P. Serc- ekus-), [email protected] (H. Okumus-).
Received 21 November 2006; received in revised form 17 January 2007; accepted 17 February 2007
Abstract Objective: to describe fears associated with childbirth and reasons for the fears. Design: a qualitative study. Data were gathered through semi-structured interviews and analysed using contentanalysis method. Setting: outpatient maternity clinic of a university hospital in Turkey. Participants: 19 nulliparous pregnant women who stated that they had fear related to childbirth. Findings: women’s fears were related to labour pain, birth-related problems and procedures, attitudes of health-care personnel and sexuality. The reasons for their fears included type and quality of childbirth information, personal characteristics and experiences, maternity ward environment and lack of confidence in health-care personnel. Seven of the women were considering an elective caesarean section. The role of husbands in the childbirth experience was not mentioned by any participants. Key conclusions and implications for practise: women experience considerable fear related to impending childbirth. Considering the potential for negative findings caused by fear, and the likelihood of requesting a caesarean section, it is important for health professionals who provide antenatal care to explore fears related to childbirth. The development and evaluation of formal childbirth education is also recommended. & 2007 Elsevier Ltd. All rights reserved. Keywords Fear of childbirth; Caesarean section; Childbirth education
Introduction Fear of childbirth can cause significant problems during childbirth and the postpartum period. Fear has been associated with more reported pain in childbirth (Saisto et al., 2001; Alehagen et al., 2005), a longer first and second stage of labour, and dissatisfaction with the childbirth experience (Saisto, 2001). Fear of childbirth has also been implicated in women’s requests for caesarean sections and a resultant increased rate of elective
caesarean sections (Jackson and Irvıne, 1998; Gamble and Creedy, 2000; Sjo ¨gren, 2000; Penna and Arulkumaran, 2003; Nerum et al., 2006; Waldenstro ¨m et al., 2006). Ryding et al. (1998a, 2000) found that severe fear of childbirth can also lead to emergency caesarean sections. To date, no studies have reported fears relating to childbirth experience among women in Turkey. Such a study is important for the following reasons. First, formal childbirth education is rare or nonexistent in rural and urban areas. At present, most
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ARTICLE IN PRESS P. Serc- ekus- , H. Okumus-
156 women in urban areas of Turkey (84%) receive their antenatal care from obstetricians or general practitioners (GPs), who see them once a month and then fortnightly in the last month. Personal choice dictates whether a pregnant woman receives care from an obstetrician or a GP. In rural areas, it is estimated that 58% of pregnant women receive care from GPs, whereas the remainder are cared for throughout their pregnancy by communitybased midwives (TDHS, 2003). The type and quality of education and counselling women receive during pregnancy in rural and urban areas depends on the health-care provider, as there are no standard approaches regarding childbirth education. Interest in establishing more standardised and available childbirth education is increasing. In order to plan and provide effective and appropriate care, it is important to understand issues of concern to women and, in particular, their common fears and the sources of these fears. Second, the rate of caesarean sections is high in Turkey (30.3%) (Koc- , 2003), exceeding the maximum medically justified rate of 15% as defined by the World Health Organization (WHO, 1985). Our clinical observations, and the findings of a study conducted in our country on women’s choice of caesarean section (C - ivili, 2005), show that fear is an important factor in electing for caesarean section. What these fears are and the sources of these fears are unknown. The aims of this study were to investigate (1) childbirth-related fears of a sample of women in their first pregnancy; (2) the sources of those fears; and (3) the thoughts of women related to choosing a caesarean section as a way of managing such fears.
Literature review Numerous studies have been published from various countries documenting women’s fears relating to childbirth. Three Swedish studies, all qualitative and with sample sizes ranging from 20 to 53, explored the fears of pregnant women (Ryding, 1993; Ryding et al., 1998b; Eriksson et al., 2006b). Data were derived from semi-structured interviews. The researchers determined that women had fears relating to labour pain, having an injury such as vaginal rupture during childbirth as well as the death of themselves or their baby. Melender and Lauri (1999) and Melender (2002a), midwives in Finland, conducted two qualitative studies to explore childbirth-related fears among women who had recently given birth. The sample size in
each study was 20, and the data were collected though interviews. Saisto et al. (1999) also explored childbirth-related fears among Finnish women, whereas Saisto and Halmesmaki (2003) conducted a review of existing research. These researchers reported similar findings, with the most common concerns being the pain associated with labour, the risk of injury to themselves or their newborn baby, the attitudes and care provided by staff in the labour ward, and complications such as heavy haemorrhage. Neuhaus et al. (1994) collected interview data from 122 women in Germany who had given birth, and also reviewed their hospital charts, to determine their fears and childbirth experience. Common fears concerning the childbirth experience included labour pain, disability or injury of the newborn baby and obstetric errors. Researchers have also explored the sources of childbirth-related fears, and found such factors as a negative mindset, negative stories heard from others around them, having pre-existing illnesses (Melender, 2002a, b), knowledge deficit (Cleeton, 2001; Melender, 2002a), receiving too much information, beliefs such as thinking they are unlucky (Melender, 2002a) and negative experiences with previous childbirth for multiparas (Areskog et al., 1981; Melender, 2002a, b) were all reported frequently. Although the findings of these studies indicate a number of commonly expressed fears and concerns relating to the childbirth experience, no studies have been reported from Turkey. This study was undertaken because fears among pregnant women can negatively affect the outcome for the mother and baby.
Method A qualitative approach was chosen as most appropriate for the determination of an individual’s feelings, interactions, perceptions and behaviours (Holloway and Wheeler, 1996). As this study was designed to seek understanding of the fears of women regarding childbirth, a qualitative design and data collection through personal interviews was selected to allow participants to freely express their thoughts and feelings (Nieswiadomy, 2002).
Setting and sample The research took place over a 4-month period in the outpatient maternity clinic of a university hospital in Izmir, Turkey, a city of 2.5 million people
ARTICLE IN PRESS Fears associated with childbirth among nulliparous women in Turkey in the west of the country. The interviews were conducted by the first author (PS) in a private room at a mutually convenient time. All nulliparous women who were healthy, had no known risks and were in the final trimester of their pregnancy were approached by the first author during a regular clinic visit, and asked if they had fears and concerns about the impending birth of their baby. All those who said they had fears were asked to participate in the study. All of these women agreed, resulting in a total of 19 women who consented to be interviewed. This was deemed an adequate sample because, by the nineteenth interview, no new information was presented and repetition and confirmation of previously collected data occurred (Morse and Field, 1996; Speziale and Carpenter, 2003).
Ethical considerations
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Each participant was asked three open-ended questions, based on the study aims. All interviews started with the same broad question: ‘Please tell me what you are thinking about childbirth?’ Two focused questions were then asked: ‘What are your fears about childbirth?’ and ‘What are the causes of your fears about childbirth?’ If participants did not mention the subject of caesarean section, they were also asked if it had been discussed with their doctor. Further questions were used to clarify or elaborate on the responses of the participants (Crabtree and Miller, 1999). Each interview took a minimum of 30 and maximum of 90 minutes, with an average time of 45 minutes. The interviews were tape-recorded and then transcribed to facilitate data collection and analysis.
Data analysis
Permission to conduct the study was received from the hospital’s ethics committee who reviewed and accepted the proposal. Potential participants were approached in the clinic by the researcher (PS) after their regular appointment and asked to participate in the study. They were given verbal and written information about the study, and given the opportunity to ask any questions concerning participation. All of the participants were informed that their participation in the study was voluntary and that their names would remain confidential. They were reassured that their care would not be affected should they choose not to participate in the study. Written consent was also received.
Analysis of the data took place at the same time as data collection. Content analysis was used in the analysis of data, using the process described by Graneheim and Lundman (2004) and Morse and Field (1996). To increase the reliability of the data analysis, the women’s statements were coded by three different individuals separately (the two authors, PS and HO, and a third individual, KY). HO and KY are senior faculty members in the Department of Obstetrics and Gynaecology of the School of Nursing which is affiliated with the hospital where data were collected. The codes were compared and the differences were discussed and re-evaluated until shared codes and categories were created (Graneheim and Lundman, 2004).
Data collection
Findings
Data were collected using a semi-structured interview technique. This method, compared with the structured interview technique, allows for flexibility and makes it possible to ask additional and more detailed questions (Holloway and Wheeler, 1996; Morse and Field, 1996). As suggested by Morse and Field (1996), a pilot study was conducted by the researcher (PS) with five nulliparous women to establish the usefulness of the questioning procedure and to develop the researcher’s interview method. Two of the interview questions were simplified as a result of the pilot study. The approach of the interviewer was found to be effective in putting the women at ease as they described their fears and concerns. The pilot study was conducted in the same setting as the full-scale study that followed.
Our participants ranged in age from 19 to 39 years (mean age 24 years); most were housewives (58%) and the remainder were employed (21% officeworkers, 16% self-employed and 5% factory workers). Most were high-school graduates (47%) and all reported they considered themselves to be middle class. All of the participants were married, because childbirth outside of marriage in Turkish culture is practically non-existent. Three main categories of findings are presented in the following sections, according to the interview questions addressed to the participants.
Fears about childbirth Fears described by the women were grouped into five main categories: labour pain, problems that
ARTICLE IN PRESS 158 can develop during labour, procedures carried out during labour, attitudes of health-care personnel, and sexuality. Labour pain The most commonly reported childbirth-related fear was fear of labour pain. Participants described their fear of pain as follows: I’m very afraid of labour pain. This is my biggest fear. I have fear all the time. What will I do if I had a lot of pain. Labour painy is the most frightful thing. These quotes indicate the level of fear related to pain, which these women expect to be a natural part of the childbirth experience. Problems that can develop during labour Some participants were afraid of problems that could develop for themselves and their babies during labour. For some women, the fear was related to panicking and losing control: I’m afraid I’ll panic. Another woman feared being unable to give birth to the baby. I’m afraid I won’t be able to do it, I won’t be able to deliver the baby. Others expressed fears of injuring themselves or their babies because of some incorrect behaviour of theirs during labour, death of themselves or their baby, being taken for emergency caesarean birth, and developing some kind of complication during labour as indicated in the following statements: I’m afraid of dying. Will there be a problem during labour? y will something break, come out? All of it comes to mind and scares people. A variety of fears were expressed, all with the potential to cause the women further stress as they advanced through their pregnancies. Procedures during childbirth Some of the participants were afraid of procedures related to the birth of their baby, including having an episiotomy, vaginal examination and the use of invasive procedures such as vacuum or forceps:
P. Serc- ekus- , H. OkumusAttitudes of health-care personnel Most participants stated that they were afraid of health-care personnel. They mentioned hearing that nurses, midwives and doctors were sometimes rude to women during labour and birth. They were afraid of being yelled at or making an error during labour. Some believed they would not have enough support during childbirth but instead would be left alone. You’re afraid. Can’t everybody make mistakes? I hope not from the doctor. Some of them don’t pay attention to you and yell at you, I’ve been told y those kinds of things stay in my head, I’m really afraid. Sexuality A few of the participants were afraid that the structure of their reproductive organs would be disturbed, that their perineum would look bad aesthetically, that they would not enjoy sex, and that their privacy would not be protected during labour: There can be some big problems getting back into shape aesthetically. That’s what I’m afraid of. This concern was expressed by several women who said it was a common topic of discussion among their friends and relatives.
Causes of childbirth related fears The causes of fears were the types and quantity of information they had received; specific personal characteristics; the maternity ward environment and health-care personnel. Type and quality of information During the interviews, most participants stated that their fears had developed because of negative stories about childbirth and health-care personnel reported by friends and family, negative information they had heard about childbirth in the media, and negative images of childbirth they had seen on television: I’ve heard from those who had normal deliveries. They told me that it always hurts. That’s why I’m so afraid now.
They examine you from below, I’m scared of that.
Some participants said their lack of information or excessive information about childbirth led to their fears. One participant explained her fears in this way:
Do they put in a lot of stitches, I don’t know. There’s fear of that.
If I didn’t know at least I wouldn’t know what could happen to me. You know, of course
ARTICLE IN PRESS Fears associated with childbirth among nulliparous women in Turkey knowing increases the fear. If you know about at least some of the things, you are aware, but there are some things that it’s better not to know about. Another participant stated that the cause of her fears was the uncertainty about how her delivery will go and about what she will experience during labour: I’m afraid. I don’t know how I’ll get through labour, what I’ll experience. Another woman stated: I’m afraid. I don’t know how this process will go. Is it going to be vaginal or caesarean section? I don’t know how I will manage it. Personal characteristics and experiences Women described personal beliefs and pre-existing health issues as sources of concern. One of the participants was afraid because she believed that she would have the same fate as her mother, who lost her first baby in childbirth. The woman feared she would lose hers as well. One participant stated she was afraid because she was overweight: I’m overweight. I wonder and worry if that will cause a problem. Another woman reported having a history of panic attack: I have had panic attacks. My doctor says I shouldn’t get stress. If I have a panic attack, I cannot breathe and my baby will not get oxygen. All these fears were related to how their labour might progress, and whether and how these conditions might negatively affect themselves or their babies during childbirth. Maternity ward environment and health-care personnel Some women stated their fears were due to the environment of the maternity ward, which they had heard about from other women. One participant stated her fear as follows: I want to just go to the delivery room and go out very fast. I do not want to hear the other women screaming. Other women expressed lack of confidence in the health-care personnel as a cause of fear. One participant explained it this way: We’re left in the hands of the physician. I’m not saying they are bad. Because no matter where
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we go we see they are really good, but still it’s hard to trust a person. Fear of childbirth and request for caesarean section Four of the participants wanted to have their babies delivered by caesarean section simply because of their fear of childbirth, three were undecided about method of birth because of their fear, and stated that they sometimes thought about requesting a caesarean section: They are telling me to have a normal delivery. I don’t want a normal delivery, I’m really scared, I want a caesarean, have them put me to sleep and when I wake up I want my baby next to be. That’s what I want.
Discussion The most commonly reported fear by women about childbirth is fear of labour pain, and women in this study further confirmed that finding (Ryding, 1993; Neuhaus et al., 1994; Ryding et al., 1998b; Melender and Lauri, 1999; Saisto et al., 1999; Melender, 2002b; Eriksson et al., 2006b). They all stated they expected to have pain and that they were afraid as a result. They wondered if they would be able to tolerate the pain. This is consistent with Saisto and Halmesmaki (2003), who also reported that tolerance of pain was a factor in the fear of childbirth. Fears relating to their own health and the health of their baby were also described by study participants. Many of the fears were for their own health or their ability to give birth safely, and included fear of dying, of complications such as haemorrhage or requiring an emergency caesarean section. Some women spoke of concerns for the baby, but this was a less common finding than in the studies of Melender and Lauri (1999) and Melender (2002a, b). In these studies, women described fears relating to the baby’s well-being, such as injury during childbirth, becoming disabled as a result of problems with childbirth or dying. Perhaps the difference in responses was due to the focus of the questions asked during interview. In our study, the women may have determined that we were interested primarily in fears they had relating to their own outcomes from labour and childbirth. Most of the women expressed fear related to the quality of care they might receive from health-care personnel. Other studies also found that women were afraid that childbirth personnel would not treat them well (Saisto et al., 1999; Melender
ARTICLE IN PRESS P. Serc- ekus- , H. Okumus-
160 2002b). The main source of this concern was information from other women and from the media, suggesting the need for education and counselling to identify and respond to such fears. Some of the women were afraid that their sexuality would be negatively affected by childbirth. Kwee et al. (2004) also found women feared that their perineum would be damaged or traumatised, and this was one reason for requesting a caesarean section. There is considerable discussion among women in Turkey about the negative effect on their sexual lives after childbirth, and this may well influence the development of these fears. However, none of the women in this study mentioned their husbands or the effect the labour and childbirth experience might have on them. Their only comment about husbands was in relation to fear of changes in their sexuality, and, in particular, how their perineum would look after childbirth. This is perhaps due to the cultural norms, where pregnancy and childbirth are considered ‘women’s business’. Husbands are not present during labour and childbirth, and women in this study did not mention having them there. There is no expected role for husbands during the process. This differs from Finnish studies, where women spoke of concerns that their husbands might not be present during childbirth or, if they were present, they might find the experience upsetting or difficult (Melender and Lauri, 1999). The primary source of fear reported by women in this study was negative stories that they had heard about childbirth or health-care personnel. Melender (2002a, b) also reported that negative experiences with childbirth cause fear, and that women share these experiences causing fear among other women. Unlike other studies, women in this study indicated that negative images of childbirth seen on television and negative news about childbirth in the media caused fear. These images and news stories can lead women to think they will experience the same negative circumstances in their own childbirth. The participants in this study indicated that knowledge deficit or too much information led to fear. In two other recent studies, knowledge deficit was found to be a cause for fear (Cleeton, 2001; Melender, 2002a). In Melender’s study (2002a), when women had been adequately informed, fear was also caused by receiving more detailed information than the women had requested. Having too much information about childbirth can cause fear in some individuals because they know about the complications that can occur in childbirth. This is probably related to individual characteristics of some women.
Another cause of fear was uncertainty about how childbirth might be affected by pre-existing health problems, such as panic attack or being overweight. Again Melender (2002b) reported similar findings, with women expressing fear that the presence of an illness in the pregnant woman herself or in her family might create problems with childbirth. In this study, concerns about the maternity ward atmosphere (seeing other women in pain, hearing the voices of other women in labour) was found to be important in the development of women’s fear of childbirth. This finding was not reported in other research. The source of this difference may be the conditions of the labour and delivery rooms in hospitals Turkey. In many hospitals, women do not have private rooms during labour, but are all together in one large room where they see and hear other women in labour. Faces that show fear arouse fear in others who see them (Ganong, 2001), so there is an increased risk that fear will be transmitted among women when they both see and hear each other. Apprehension about the competence of health-care personnel was also identified as a source of fear in this study, a finding that was different from other studies. This may be due to the inadequate number and education of healthcare personnel in some regions of our country. As with other researchers, we found that fear of childbirth is likely to lead to requests by women to have a caesarean section. This in turn may be a factor in the high rate of caesarean sections in Turkey. There is considerable evidence that women’s fear of childbirth play a primary role in requesting caesarean sections (Jackson and Irvıne, 1998; Ryding, 1991; Gamble and Creedy, 2000; Sjo ¨gren, 2000; Bewley and Cockburn, 2002; Penna and Arulkumaran, 2003; Eriksson et al., 2006a; Nerum et al., 2006; Waldenstro ¨m et al., 2006).
Conclusions This study indicates that women anticipate pain and feelings of inadequacy during childbirth. Several women mentioned that, because of their fears, caesarean section rather than vaginal delivery would be preferred. Information about the childbirth process is learnt primarily from women who have had a baby and from the media. At present, there are no formal childbirth preparation classes in Turkey. Given that the type and quality of education women receive has been shown to influence the process and outcome of childbirth (Melender, 2002a, b), the development of a
ARTICLE IN PRESS Fears associated with childbirth among nulliparous women in Turkey systematic process of childbirth education should be a priority for health care in Turkey. This would ensure the careful assessment of pregnant women to determine their fears and worries, which should also be a part of all continuing antenatal care. Providing opportunities for women who have fear of giving birth to communicate with those who had favourable experiences giving birth is a suggested strategy for reducing fear. The findings also highlight the need for careful review of the existing labour and delivery units and procedures. More privacy during labour might reduce fear and improve education about the procedures and process of labour and childbirth should prove useful. Midwives and nurses who work in labour and delivery should be encouraged to assess and respond to their patient’s feelings and concerns about childbirth. Perhaps increasing the role of husbands in the childbirth experience is warranted. All of these suggestions for practice should be carefully considered, and any initiatives implemented to reduce levels of fear should be carefully evaluated. A first research step should be further exploration of what women themselves would recommend as useful strategies to reduce childbirth-related fear. This study was conducted in a university-affiliated hospital in a large urban area, so cannot be said to represent the experience of most Turkish women. Further studies focusing on women in rural and underserviced areas of the country are required to gain understanding of the fears and experiences of a broader range of Turkish women. It would also be useful to explore the perceptions of midwives and nurses concerning women’s fears and their suggestions for effective actions and responses.
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Fears associated with childbirth among nulliparous women in Turkey Pınar Serc-ekus- , MSc, RN (Research Assistant), Hu ¨lya Okumus-, Phd, RN (Professor) ´nciralty´, Y ´ZMY ´R 35340 Turkey Dokuz Eylu ¨ l University School of Nursing, Mithatpaba Street, Y
Corresponding author.
E-mail addresses: [email protected] (P. Serc- ekus-), [email protected] (H. Okumus-).
Received 21 November 2006; received in revised form 17 January 2007; accepted 17 February 2007
Abstract Objective: to describe fears associated with childbirth and reasons for the fears. Design: a qualitative study. Data were gathered through semi-structured interviews and analysed using contentanalysis method. Setting: outpatient maternity clinic of a university hospital in Turkey. Participants: 19 nulliparous pregnant women who stated that they had fear related to childbirth. Findings: women’s fears were related to labour pain, birth-related problems and procedures, attitudes of health-care personnel and sexuality. The reasons for their fears included type and quality of childbirth information, personal characteristics and experiences, maternity ward environment and lack of confidence in health-care personnel. Seven of the women were considering an elective caesarean section. The role of husbands in the childbirth experience was not mentioned by any participants. Key conclusions and implications for practise: women experience considerable fear related to impending childbirth. Considering the potential for negative findings caused by fear, and the likelihood of requesting a caesarean section, it is important for health professionals who provide antenatal care to explore fears related to childbirth. The development and evaluation of formal childbirth education is also recommended. & 2007 Elsevier Ltd. All rights reserved. Keywords Fear of childbirth; Caesarean section; Childbirth education
Introduction Fear of childbirth can cause significant problems during childbirth and the postpartum period. Fear has been associated with more reported pain in childbirth (Saisto et al., 2001; Alehagen et al., 2005), a longer first and second stage of labour, and dissatisfaction with the childbirth experience (Saisto, 2001). Fear of childbirth has also been implicated in women’s requests for caesarean sections and a resultant increased rate of elective
caesarean sections (Jackson and Irvıne, 1998; Gamble and Creedy, 2000; Sjo ¨gren, 2000; Penna and Arulkumaran, 2003; Nerum et al., 2006; Waldenstro ¨m et al., 2006). Ryding et al. (1998a, 2000) found that severe fear of childbirth can also lead to emergency caesarean sections. To date, no studies have reported fears relating to childbirth experience among women in Turkey. Such a study is important for the following reasons. First, formal childbirth education is rare or nonexistent in rural and urban areas. At present, most
0266-6138/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2007.02.005
ARTICLE IN PRESS P. Serc- ekus- , H. Okumus-
156 women in urban areas of Turkey (84%) receive their antenatal care from obstetricians or general practitioners (GPs), who see them once a month and then fortnightly in the last month. Personal choice dictates whether a pregnant woman receives care from an obstetrician or a GP. In rural areas, it is estimated that 58% of pregnant women receive care from GPs, whereas the remainder are cared for throughout their pregnancy by communitybased midwives (TDHS, 2003). The type and quality of education and counselling women receive during pregnancy in rural and urban areas depends on the health-care provider, as there are no standard approaches regarding childbirth education. Interest in establishing more standardised and available childbirth education is increasing. In order to plan and provide effective and appropriate care, it is important to understand issues of concern to women and, in particular, their common fears and the sources of these fears. Second, the rate of caesarean sections is high in Turkey (30.3%) (Koc- , 2003), exceeding the maximum medically justified rate of 15% as defined by the World Health Organization (WHO, 1985). Our clinical observations, and the findings of a study conducted in our country on women’s choice of caesarean section (C - ivili, 2005), show that fear is an important factor in electing for caesarean section. What these fears are and the sources of these fears are unknown. The aims of this study were to investigate (1) childbirth-related fears of a sample of women in their first pregnancy; (2) the sources of those fears; and (3) the thoughts of women related to choosing a caesarean section as a way of managing such fears.
Literature review Numerous studies have been published from various countries documenting women’s fears relating to childbirth. Three Swedish studies, all qualitative and with sample sizes ranging from 20 to 53, explored the fears of pregnant women (Ryding, 1993; Ryding et al., 1998b; Eriksson et al., 2006b). Data were derived from semi-structured interviews. The researchers determined that women had fears relating to labour pain, having an injury such as vaginal rupture during childbirth as well as the death of themselves or their baby. Melender and Lauri (1999) and Melender (2002a), midwives in Finland, conducted two qualitative studies to explore childbirth-related fears among women who had recently given birth. The sample size in
each study was 20, and the data were collected though interviews. Saisto et al. (1999) also explored childbirth-related fears among Finnish women, whereas Saisto and Halmesmaki (2003) conducted a review of existing research. These researchers reported similar findings, with the most common concerns being the pain associated with labour, the risk of injury to themselves or their newborn baby, the attitudes and care provided by staff in the labour ward, and complications such as heavy haemorrhage. Neuhaus et al. (1994) collected interview data from 122 women in Germany who had given birth, and also reviewed their hospital charts, to determine their fears and childbirth experience. Common fears concerning the childbirth experience included labour pain, disability or injury of the newborn baby and obstetric errors. Researchers have also explored the sources of childbirth-related fears, and found such factors as a negative mindset, negative stories heard from others around them, having pre-existing illnesses (Melender, 2002a, b), knowledge deficit (Cleeton, 2001; Melender, 2002a), receiving too much information, beliefs such as thinking they are unlucky (Melender, 2002a) and negative experiences with previous childbirth for multiparas (Areskog et al., 1981; Melender, 2002a, b) were all reported frequently. Although the findings of these studies indicate a number of commonly expressed fears and concerns relating to the childbirth experience, no studies have been reported from Turkey. This study was undertaken because fears among pregnant women can negatively affect the outcome for the mother and baby.
Method A qualitative approach was chosen as most appropriate for the determination of an individual’s feelings, interactions, perceptions and behaviours (Holloway and Wheeler, 1996). As this study was designed to seek understanding of the fears of women regarding childbirth, a qualitative design and data collection through personal interviews was selected to allow participants to freely express their thoughts and feelings (Nieswiadomy, 2002).
Setting and sample The research took place over a 4-month period in the outpatient maternity clinic of a university hospital in Izmir, Turkey, a city of 2.5 million people
ARTICLE IN PRESS Fears associated with childbirth among nulliparous women in Turkey in the west of the country. The interviews were conducted by the first author (PS) in a private room at a mutually convenient time. All nulliparous women who were healthy, had no known risks and were in the final trimester of their pregnancy were approached by the first author during a regular clinic visit, and asked if they had fears and concerns about the impending birth of their baby. All those who said they had fears were asked to participate in the study. All of these women agreed, resulting in a total of 19 women who consented to be interviewed. This was deemed an adequate sample because, by the nineteenth interview, no new information was presented and repetition and confirmation of previously collected data occurred (Morse and Field, 1996; Speziale and Carpenter, 2003).
Ethical considerations
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Each participant was asked three open-ended questions, based on the study aims. All interviews started with the same broad question: ‘Please tell me what you are thinking about childbirth?’ Two focused questions were then asked: ‘What are your fears about childbirth?’ and ‘What are the causes of your fears about childbirth?’ If participants did not mention the subject of caesarean section, they were also asked if it had been discussed with their doctor. Further questions were used to clarify or elaborate on the responses of the participants (Crabtree and Miller, 1999). Each interview took a minimum of 30 and maximum of 90 minutes, with an average time of 45 minutes. The interviews were tape-recorded and then transcribed to facilitate data collection and analysis.
Data analysis
Permission to conduct the study was received from the hospital’s ethics committee who reviewed and accepted the proposal. Potential participants were approached in the clinic by the researcher (PS) after their regular appointment and asked to participate in the study. They were given verbal and written information about the study, and given the opportunity to ask any questions concerning participation. All of the participants were informed that their participation in the study was voluntary and that their names would remain confidential. They were reassured that their care would not be affected should they choose not to participate in the study. Written consent was also received.
Analysis of the data took place at the same time as data collection. Content analysis was used in the analysis of data, using the process described by Graneheim and Lundman (2004) and Morse and Field (1996). To increase the reliability of the data analysis, the women’s statements were coded by three different individuals separately (the two authors, PS and HO, and a third individual, KY). HO and KY are senior faculty members in the Department of Obstetrics and Gynaecology of the School of Nursing which is affiliated with the hospital where data were collected. The codes were compared and the differences were discussed and re-evaluated until shared codes and categories were created (Graneheim and Lundman, 2004).
Data collection
Findings
Data were collected using a semi-structured interview technique. This method, compared with the structured interview technique, allows for flexibility and makes it possible to ask additional and more detailed questions (Holloway and Wheeler, 1996; Morse and Field, 1996). As suggested by Morse and Field (1996), a pilot study was conducted by the researcher (PS) with five nulliparous women to establish the usefulness of the questioning procedure and to develop the researcher’s interview method. Two of the interview questions were simplified as a result of the pilot study. The approach of the interviewer was found to be effective in putting the women at ease as they described their fears and concerns. The pilot study was conducted in the same setting as the full-scale study that followed.
Our participants ranged in age from 19 to 39 years (mean age 24 years); most were housewives (58%) and the remainder were employed (21% officeworkers, 16% self-employed and 5% factory workers). Most were high-school graduates (47%) and all reported they considered themselves to be middle class. All of the participants were married, because childbirth outside of marriage in Turkish culture is practically non-existent. Three main categories of findings are presented in the following sections, according to the interview questions addressed to the participants.
Fears about childbirth Fears described by the women were grouped into five main categories: labour pain, problems that
ARTICLE IN PRESS 158 can develop during labour, procedures carried out during labour, attitudes of health-care personnel, and sexuality. Labour pain The most commonly reported childbirth-related fear was fear of labour pain. Participants described their fear of pain as follows: I’m very afraid of labour pain. This is my biggest fear. I have fear all the time. What will I do if I had a lot of pain. Labour painy is the most frightful thing. These quotes indicate the level of fear related to pain, which these women expect to be a natural part of the childbirth experience. Problems that can develop during labour Some participants were afraid of problems that could develop for themselves and their babies during labour. For some women, the fear was related to panicking and losing control: I’m afraid I’ll panic. Another woman feared being unable to give birth to the baby. I’m afraid I won’t be able to do it, I won’t be able to deliver the baby. Others expressed fears of injuring themselves or their babies because of some incorrect behaviour of theirs during labour, death of themselves or their baby, being taken for emergency caesarean birth, and developing some kind of complication during labour as indicated in the following statements: I’m afraid of dying. Will there be a problem during labour? y will something break, come out? All of it comes to mind and scares people. A variety of fears were expressed, all with the potential to cause the women further stress as they advanced through their pregnancies. Procedures during childbirth Some of the participants were afraid of procedures related to the birth of their baby, including having an episiotomy, vaginal examination and the use of invasive procedures such as vacuum or forceps:
P. Serc- ekus- , H. OkumusAttitudes of health-care personnel Most participants stated that they were afraid of health-care personnel. They mentioned hearing that nurses, midwives and doctors were sometimes rude to women during labour and birth. They were afraid of being yelled at or making an error during labour. Some believed they would not have enough support during childbirth but instead would be left alone. You’re afraid. Can’t everybody make mistakes? I hope not from the doctor. Some of them don’t pay attention to you and yell at you, I’ve been told y those kinds of things stay in my head, I’m really afraid. Sexuality A few of the participants were afraid that the structure of their reproductive organs would be disturbed, that their perineum would look bad aesthetically, that they would not enjoy sex, and that their privacy would not be protected during labour: There can be some big problems getting back into shape aesthetically. That’s what I’m afraid of. This concern was expressed by several women who said it was a common topic of discussion among their friends and relatives.
Causes of childbirth related fears The causes of fears were the types and quantity of information they had received; specific personal characteristics; the maternity ward environment and health-care personnel. Type and quality of information During the interviews, most participants stated that their fears had developed because of negative stories about childbirth and health-care personnel reported by friends and family, negative information they had heard about childbirth in the media, and negative images of childbirth they had seen on television: I’ve heard from those who had normal deliveries. They told me that it always hurts. That’s why I’m so afraid now.
They examine you from below, I’m scared of that.
Some participants said their lack of information or excessive information about childbirth led to their fears. One participant explained her fears in this way:
Do they put in a lot of stitches, I don’t know. There’s fear of that.
If I didn’t know at least I wouldn’t know what could happen to me. You know, of course
ARTICLE IN PRESS Fears associated with childbirth among nulliparous women in Turkey knowing increases the fear. If you know about at least some of the things, you are aware, but there are some things that it’s better not to know about. Another participant stated that the cause of her fears was the uncertainty about how her delivery will go and about what she will experience during labour: I’m afraid. I don’t know how I’ll get through labour, what I’ll experience. Another woman stated: I’m afraid. I don’t know how this process will go. Is it going to be vaginal or caesarean section? I don’t know how I will manage it. Personal characteristics and experiences Women described personal beliefs and pre-existing health issues as sources of concern. One of the participants was afraid because she believed that she would have the same fate as her mother, who lost her first baby in childbirth. The woman feared she would lose hers as well. One participant stated she was afraid because she was overweight: I’m overweight. I wonder and worry if that will cause a problem. Another woman reported having a history of panic attack: I have had panic attacks. My doctor says I shouldn’t get stress. If I have a panic attack, I cannot breathe and my baby will not get oxygen. All these fears were related to how their labour might progress, and whether and how these conditions might negatively affect themselves or their babies during childbirth. Maternity ward environment and health-care personnel Some women stated their fears were due to the environment of the maternity ward, which they had heard about from other women. One participant stated her fear as follows: I want to just go to the delivery room and go out very fast. I do not want to hear the other women screaming. Other women expressed lack of confidence in the health-care personnel as a cause of fear. One participant explained it this way: We’re left in the hands of the physician. I’m not saying they are bad. Because no matter where
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we go we see they are really good, but still it’s hard to trust a person. Fear of childbirth and request for caesarean section Four of the participants wanted to have their babies delivered by caesarean section simply because of their fear of childbirth, three were undecided about method of birth because of their fear, and stated that they sometimes thought about requesting a caesarean section: They are telling me to have a normal delivery. I don’t want a normal delivery, I’m really scared, I want a caesarean, have them put me to sleep and when I wake up I want my baby next to be. That’s what I want.
Discussion The most commonly reported fear by women about childbirth is fear of labour pain, and women in this study further confirmed that finding (Ryding, 1993; Neuhaus et al., 1994; Ryding et al., 1998b; Melender and Lauri, 1999; Saisto et al., 1999; Melender, 2002b; Eriksson et al., 2006b). They all stated they expected to have pain and that they were afraid as a result. They wondered if they would be able to tolerate the pain. This is consistent with Saisto and Halmesmaki (2003), who also reported that tolerance of pain was a factor in the fear of childbirth. Fears relating to their own health and the health of their baby were also described by study participants. Many of the fears were for their own health or their ability to give birth safely, and included fear of dying, of complications such as haemorrhage or requiring an emergency caesarean section. Some women spoke of concerns for the baby, but this was a less common finding than in the studies of Melender and Lauri (1999) and Melender (2002a, b). In these studies, women described fears relating to the baby’s well-being, such as injury during childbirth, becoming disabled as a result of problems with childbirth or dying. Perhaps the difference in responses was due to the focus of the questions asked during interview. In our study, the women may have determined that we were interested primarily in fears they had relating to their own outcomes from labour and childbirth. Most of the women expressed fear related to the quality of care they might receive from health-care personnel. Other studies also found that women were afraid that childbirth personnel would not treat them well (Saisto et al., 1999; Melender
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160 2002b). The main source of this concern was information from other women and from the media, suggesting the need for education and counselling to identify and respond to such fears. Some of the women were afraid that their sexuality would be negatively affected by childbirth. Kwee et al. (2004) also found women feared that their perineum would be damaged or traumatised, and this was one reason for requesting a caesarean section. There is considerable discussion among women in Turkey about the negative effect on their sexual lives after childbirth, and this may well influence the development of these fears. However, none of the women in this study mentioned their husbands or the effect the labour and childbirth experience might have on them. Their only comment about husbands was in relation to fear of changes in their sexuality, and, in particular, how their perineum would look after childbirth. This is perhaps due to the cultural norms, where pregnancy and childbirth are considered ‘women’s business’. Husbands are not present during labour and childbirth, and women in this study did not mention having them there. There is no expected role for husbands during the process. This differs from Finnish studies, where women spoke of concerns that their husbands might not be present during childbirth or, if they were present, they might find the experience upsetting or difficult (Melender and Lauri, 1999). The primary source of fear reported by women in this study was negative stories that they had heard about childbirth or health-care personnel. Melender (2002a, b) also reported that negative experiences with childbirth cause fear, and that women share these experiences causing fear among other women. Unlike other studies, women in this study indicated that negative images of childbirth seen on television and negative news about childbirth in the media caused fear. These images and news stories can lead women to think they will experience the same negative circumstances in their own childbirth. The participants in this study indicated that knowledge deficit or too much information led to fear. In two other recent studies, knowledge deficit was found to be a cause for fear (Cleeton, 2001; Melender, 2002a). In Melender’s study (2002a), when women had been adequately informed, fear was also caused by receiving more detailed information than the women had requested. Having too much information about childbirth can cause fear in some individuals because they know about the complications that can occur in childbirth. This is probably related to individual characteristics of some women.
Another cause of fear was uncertainty about how childbirth might be affected by pre-existing health problems, such as panic attack or being overweight. Again Melender (2002b) reported similar findings, with women expressing fear that the presence of an illness in the pregnant woman herself or in her family might create problems with childbirth. In this study, concerns about the maternity ward atmosphere (seeing other women in pain, hearing the voices of other women in labour) was found to be important in the development of women’s fear of childbirth. This finding was not reported in other research. The source of this difference may be the conditions of the labour and delivery rooms in hospitals Turkey. In many hospitals, women do not have private rooms during labour, but are all together in one large room where they see and hear other women in labour. Faces that show fear arouse fear in others who see them (Ganong, 2001), so there is an increased risk that fear will be transmitted among women when they both see and hear each other. Apprehension about the competence of health-care personnel was also identified as a source of fear in this study, a finding that was different from other studies. This may be due to the inadequate number and education of healthcare personnel in some regions of our country. As with other researchers, we found that fear of childbirth is likely to lead to requests by women to have a caesarean section. This in turn may be a factor in the high rate of caesarean sections in Turkey. There is considerable evidence that women’s fear of childbirth play a primary role in requesting caesarean sections (Jackson and Irvıne, 1998; Ryding, 1991; Gamble and Creedy, 2000; Sjo ¨gren, 2000; Bewley and Cockburn, 2002; Penna and Arulkumaran, 2003; Eriksson et al., 2006a; Nerum et al., 2006; Waldenstro ¨m et al., 2006).
Conclusions This study indicates that women anticipate pain and feelings of inadequacy during childbirth. Several women mentioned that, because of their fears, caesarean section rather than vaginal delivery would be preferred. Information about the childbirth process is learnt primarily from women who have had a baby and from the media. At present, there are no formal childbirth preparation classes in Turkey. Given that the type and quality of education women receive has been shown to influence the process and outcome of childbirth (Melender, 2002a, b), the development of a
ARTICLE IN PRESS Fears associated with childbirth among nulliparous women in Turkey systematic process of childbirth education should be a priority for health care in Turkey. This would ensure the careful assessment of pregnant women to determine their fears and worries, which should also be a part of all continuing antenatal care. Providing opportunities for women who have fear of giving birth to communicate with those who had favourable experiences giving birth is a suggested strategy for reducing fear. The findings also highlight the need for careful review of the existing labour and delivery units and procedures. More privacy during labour might reduce fear and improve education about the procedures and process of labour and childbirth should prove useful. Midwives and nurses who work in labour and delivery should be encouraged to assess and respond to their patient’s feelings and concerns about childbirth. Perhaps increasing the role of husbands in the childbirth experience is warranted. All of these suggestions for practice should be carefully considered, and any initiatives implemented to reduce levels of fear should be carefully evaluated. A first research step should be further exploration of what women themselves would recommend as useful strategies to reduce childbirth-related fear. This study was conducted in a university-affiliated hospital in a large urban area, so cannot be said to represent the experience of most Turkish women. Further studies focusing on women in rural and underserviced areas of the country are required to gain understanding of the fears and experiences of a broader range of Turkish women. It would also be useful to explore the perceptions of midwives and nurses concerning women’s fears and their suggestions for effective actions and responses.
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