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DOI: 10.1111/j.1471-0528.2007.01583.x www.blackwellpublishing.

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Epidemiology

Fear of childbirth: predictors and temporal changes among nulliparous women in the Danish National Birth Cohort
M Laursen,a,b M Hedegaard,a C Johansenb
a Department of Obstetrics, Rigshospitalet, University Hospital of Copenhagen, Copenhagen , Denmark b Department of Psychosocial Cancer Research, Institute of Cancer Epidemiology, Strandboulevarden, Copenhagen , Denmark Correspondence: Dr M Laursen, Department of Psychosocial Cancer Research, Institute of Cancer Epidemiology, Strandboulevarden 49, DK 2100 Copenhagen , Denmark. Email majaduus@hotmail.com

Accepted 7 October 2007.

Objectives To describe the association between fear of childbirth

and social, demographic and psychological factors in a cohort of 30 480 healthy nulliparous women with uncomplicated singleton pregnancies.
Design Nationwide population-based study. Setting The Danish National Birth Cohort. Population Healthy nulliparous women (n = 30 480) with

for fear of childbirth among women with anxiety symptoms was 4.8 (4.15.7) after adjustment for socio-demographic, lifestyle, fertility and depression variables. During the study period, the prevalence of fear of childbirth was stable. Fear of childbirth was reported by 7.6% in early pregnancy and 7.4% in late pregnancy. Only 3.2% of the women expressed fear of childbirth in both interviews.
Conclusions The prevalence of fear of childbirth among healthy

singleton pregnancies.
Methods Data from computer-assisted telephone interviews twice in pregnancy linked with national health registers. Main outcome measures Characteristics of women with fear of

childbirth in early (mean, 16 weeks) and late pregnancy (mean, 32 weeks) and changes in fear of childbirth between 1997 and 2003.
Results Low educational level, lack of a social network, young age and unemployment were associated with fear of childbirth, as were being a smoker and having low self-rated health. The odds ratio

nulliparous women with singleton pregnancies did not increase during the study period. Fear of childbirth among nulliparous women was most often seen in individuals with few social and psychological resources. Testing the women twice, we found the same prevalence of fear in early and late pregnancy, but found that half the women who expressed fear during early pregnancy had no fear later in pregnancy, an effect that was counterbalanced by a similar number of women who became fearful between the two interviews.
Keywords Fear of childbirth, socio-demographics.

Please cite this paper as: Laursen M, Hedegaard M, Johansen C. Fear of childbirth: predictors and temporal changes among nulliparous women in the Danish National Birth Cohort. BJOG 2008;115:354360.

Introduction
An increasing number of women wish to deliver by caesarean section without a medical indication,1 and it has been suggested that such requests are because of fear of childbirth.16 It has been found that women with anxiety or depression are more likely to fear childbirth,711 but the social and demographic characteristics associated with fear of childbirth have been explored to only a limited extent. A Finnish study of 278 women in early pregnancy linked unemployment, a poor social network and dissatisfaction with their partnership with fear of childbirth;9 however, neither this study nor two

others10,12 showed a link with age or educational level. These studies had few participants, and the study by Lowe10 concerned a selected population, reducing the possibility for nding possible explanations for fear of childbirth, as random variation could have affected the results. We believed that a large cohort was needed to study fear of childbirth and socio-demographic and psychological variables properly and, furthermore, to study changes over time in the prevalence of fear of childbirth in a cohort that covered a 7-year period. This paper presents the results of a large, nationwide, population-based study of the association between socio-demographic

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characteristics, psychological status and fear of childbirth and the prevalence of fear over time.

Methods
We included only nulliparous women, as it has been observed that a previous birth affects fear of childbirth in the subsequent pregnancy.2,5,6,13,14 We identied healthy nulliparae in the Danish National Birth Cohort (DNBC)15 of 100 000 women, who had an uncomplicated singleton pregnancy in the period 19972003. The aim of the DNBC was to enable research on associations between exposure in fetal life and later disease. The available data included detailed obstetric and clinical information that might have influenced fear of childbirth. In the period 19972003, all GPs in Denmark, who see 99% of pregnant women,15 were asked to enrol all women uent in Danish at their rst antenatal visit, which usually takes place between weeks 6 and 12. Of the eligible women, 50% were not invited to participate because the GP did not support their recruitment into the DNBC. It has been estimated that approximately 30% of women in Denmark who were pregnant during the recruitment period participated.15,16 For this study, we used data obtained from telephone interviews conducted twice during pregnancy and from two-register linkage procedures. The rst interview (interview I), conducted at gestational week 16 on average, provided data on educational level, partnership, social network, size of residence, lifestyle, obstetric history, self-rated health and fear of childbirth. The second interview (interview II), conducted at gestational week 32 on average, covered anxiety, depression and fear of childbirth together with information not relevant for this study. The two interviews were undertaken by different interviewers. Fear of childbirth was assessed asking the question Are you anxious about the course of the upcoming delivery? Possible responses were: Not at all, A little or A lot. Only the last response was considered to represent fear of childbirth. Assessment of educational level was based on job type, or for the 18% of the women who were students, their predicted educational level. Unemployed women were put in a separate category. Anxiety was assessed from answers to the question, During your pregnancy, have you been anxious and afraid for no reason?, and symptoms of depression were assessed by asking. Have you felt down and blue during your pregnancy? Participants in the DNBC were linked to the Danish Medical Birth Registry, which was established in 1968 and contains medical and socio-demographic data on all deliveries and newborn children in Denmark.17 This linkage added information on duration of pregnancy, place of residence and the date of birth of the child. We thus included 40 156 nulliparous women with singleton liveborn infants. We excluded 2846 women (7.1%) who participated only in interview I, 2325 women (5.8%) who participated in interview I after week 24, 406 women (1.0%) who

participated in interview II before week 26 or after week 40 and 10 women (0.02%) who participated in interview II after giving birth or who did not reply to the question about fear of childbirth. This left 34 569 women (86%) for registry linkage. Subsequently, the cohort was linked to the populationbased National Register of Patients, which contains records of more than 99% of all hospital discharges for somatic conditions since 1977 and data on outpatient visits since 1995.18 The information on each woman includes date of diagnosis and the unique ten-digit civil registration number assigned to all individuals in Denmark since 1 April 1968. The diagnoses used in this study were classied according to a Danish modication of the ICD-10. We excluded 1161 women (2.9%) who had a complicated medical condition not related to pregnancy, 14 women (0.04%) diagnosed with substance abuse and 89 women (0.2%) with a malformation of the uterus or other conditions that might interfere with vaginal delivery. We then excluded 111 (0.3%) women with a diagnosis of fetal malformation or fetal genetic abnormality at any time during pregnancy, 533 (1.3%) women who had complications related to the fetus, 694 women (1.7%) with various maternal complications, 234 women (0.6%) with complications related to the placenta or amnion uid quantity and 205 women (0.5%) with threatened premature delivery, if this was diagnosed before interview II. Finally, 45 women (0.1%) who had a planned caesarean section within 2 weeks of interview II were excluded. This left 31 479 (78.4%) women for the analyses. Data on some of the variables in Table 2 were missing for 999 women. As we included only women for whom complete data were available in the multivariate logistic regression analyses, the cohort was reduced to 30 480 women (75.9%).

Statistical analyses
A logistic regression model was used to calculate the odds ratio for fear of childbirth at interview II, depending on the variables. The odds ratio was rst calculated for each variable with adjustment for maternal age and duration of pregnancy at the time of interview II and then adjusted in a multivariate model with selected variables. Subsequently, a similar analysis was made with the inclusion of anxiety and depression variables in the model. Information on variables was obtained at interview I, except for residential area and the date of birth of the child, which were obtained from the Medical Birth Registry, and the data on anxiety and depression, which were obtained at interview II. Duration of pregnancy at the time of interview was entered into the model as a continuous variable. The variable for calendar time was the date of interview II, which was used as a continuous variable in the model.

Results
Table 1 gives data on the demographics, networks, physical and psychological health and lifestyle of the cohort and the

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Table 1. Description of 30 480 women in the cohort* No. women** and percentage of all women Fear of childbirth at interviews. No. women with fear and (%) of women with fear within each category Interview I All women 30 480 (100) Socio-demographics Maternal age (years)*** ,20 532 (1.8) 2024 6053 (19.9) 2529 15 945 (52.3) 3034 6622 (21.4) 35 1428 (4.7) Educational level/years of education (employees or students) or unemployment University level/17 6397 (21.0) BA level/1416 10 216 (33.5) Vocational training/1113 9896 (32.5) Unskilled/912 1231 (4.0) Unemployed, unspecied educational level 2740 (9.0) Residential area*** Big cities 12 035 (39.5) Smaller cities/rural 18 445 (60.5) Size of residence (m2) ,60 1638 (5.4) 60 28 842 (94.6) Partner Yes 29 829 (97.9) No 651 (2.1) Network Family contact frequency Every day 13 834 (45.4) Less than every day 16 646 (54.6) Network (practical/close friend/economical support) Complete 27 643 (90.7) Not complete 2837 (9.3) Health Previous abortions Induced only 3574 (11.7) Spontaneous (1/2 induced) 4009 (13.2) None 22 883 (75.1) Waiting time to pregnancy Not planned 3936 (12.9) ,6 months 11 319 (37.1) 6 months 15 225 (50.0) Infertility treatment**** Yes 2484 (8.2) No 27 996 (91.9) BMI before pregnancy ,18.5 1277 (4.3) 18.524.9 21 074 (70.4) 2529.9 5436 (18.2) 30 2134 (7.1) Self-rated health Very good 17 038 (55.9) 2308 (100) Interview II 2245 (100)

84 (3.6) 487 (21.1) 1095 (47.4) 502 (21.7) 140 (6.1) 375 (16.2) 669 (29.0) 816 (35.4) 128 (5.5) 320 (13.9) 835 (36.2) 1473 (63.8) 173 (7.5) 2135 (92.5) 2215 (96.0) 93 (4.0)

89 (4.0) 523 (23.3) 1054 (47.0) 469 (20.9) 110 (4.9) 311 (13.9) 645 (28.7) 867 (38.6) 134 (6.0) 288 (12.8) 766 (34.1) 1479 (65.9) 168 (7.5) 2077 (92.5) 2163 (96.4) 82 (3.7)

1190 (51.6) 1118 (48.4) 1984 (86.0) 324 (14.0)

1185 (52.8) 1060 (47.2) 1931(86.0) 314 (14.0)

319 (13.8) 436 (18.9) 1553 (67.3) 420 (18.2) 779 (33.8) 1109 (4.7) 218 (9.5) 2090 (90.6) 120 (5.2) 1521 (65.9) 420 (18.2) 200 (8.7) 1133 (49.1)

278 (12.3) 321 (14.3) 1645 (73.3) 404 (18.0) 746 (33.2) 1095 (48.8) 185 (8.2) 2060 (91.8) 98 (4.4) 1473 (65.6) 424 (18.9) 188 (8.4) 1083 (48.2) (continued )

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Table 1. (Continued ) No. women** and percentage of all women Fear of childbirth at interviews. No. women with fear and (%) of women with fear within each category Interview I Normal/do not know 12 735 (41.8) Less good 707 (2.3) Lifestyle Smoking Nonsmoker 22 268 (73.1) Occasionally/stopped 4293 (14.1) Smoker 3919 (12.9) Physical activity Yes 13 907 (45.6) No 16 564 (54.4) Alcohol units/week before pregnancy 0 2911 (9.7) 1/2 to ,3 15 341 (50.7) 37 8190 (27.0) .7 3859 (12.7) Psychological health***** Anxiety symptoms Have you during pregnancy been anxious and afraid for no reason No 20 498 (67.3) A little 8971 (29.4) A lot 1011 (3.3) Depression symptoms***** Have you during pregnancy felt down and blue No 18 525 (60.8) A little 11 059 (36.3) A lot 896 (2.9) 1053 (45.6) 122 (5.3) Interview II 1065 (47.4) 97 (4.3)

1495 (64.8) 368 (16.0) 445 (19.3) 899 (39.0) 1409 (61.1) 298 (12.9) 1116 (48.6) 553 (24.0) 330 (14.3)

1412 (62.9) 363 (16.2) 470 (20.9) 889 (39.6) 1356 (60.4) 297 (13.2) 1115 (49.7) 530 (23.6) 285 (12.7)

1031 (45.9) 931 (41.5) 283 (12.6)

928 (41.3) 1105 (49.2) 212 (9.4)

*30 480 women were used for the multivariate analyses (Tables 2 and 3) and had no missing data for the variables used. In this table, there were missing data for 14 women about abortion, 559 about BMI, 9 for physical activity and 179 for alcohol consumption before pregnancy. **Information from interview I unless otherwise stated. ***Information from The Medical Birth Registry. ****Only asked if time to pregnancy was 6 months. Women with ,6 months to pregnancy were classied as no infertility treatment. *****Information from interview II.

numbers and percentages of women in each category. For interview I and interview II we present the number and percentage of women reporting fear, respectively. The overall frequency of fear was 7.6% at interview I and 7.4% at interview II; only 3.2% of the women reported fear at both interviews. By multivariate logistic regression with adjustment for duration of pregnancy at interview II and the variables listed in Table 2, we observed that self-rated health was the most important risk factor for fear of childbirth, followed by lack of a social network, an unskilled job or vocational education, being a current smoker, young age and unemployment (educational level unspecied) (Table 2). Symptoms of anxiety were associated with an almost ve-fold increase in fear of

childbirth, and symptoms of depression with a more than two-fold increase when adjusted mutually and when adjusted for socio-demographic and health factors (Table 3). We found a stable prevalence of fear of childbirth in the period 19972003 (Table 2). In a logistic regression analysis with the variables listed in Table 2 and the outcome fear of childbirth at interview I, we found only minor differences from the results shown in Table 2 (data not shown). Similarly, an analysis including women reporting fear of childbirth at both interviews versus those never reporting fear did not change the results (data not shown). Among the 2207 women (reduced from 2846 women by the same exclusion criteria as for the analysed cohort) who did not respond to interview II, the frequency of fear of childbirth was 10.3% at interview I.

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Table 2. Fear of childbirth at interview II in 30 480 women*


Odds ratio (95% CI)

Table 3. Psychological health and fear of childbirth at interview II in 30 480 women Odds ratio (95% CI)

Adjusted for maternal age and duration of pregnancy at interview II

Adjusted for all variables in table and duration of pregnancy at interview II

Adjusted for maternal Adjusted for variables age and duration in Tables 2 and 3 of pregnancy and duration of pregnancy at interview II at interview II Anxiety symptoms Have you during pregnancy been anxious and afraid for no reason No 1 1 A little 2.18 (1.982.39) 1.83 (1.662.01) A lot 7.14 (6.148.31) 4.80 (4.075.66) Depression symptoms Have you during pregnancy felt down and blue No 1 1 A little 2.07 (1.892.27) 1.57 (1.431.73) A lot 5.52 (4.666.55) 2.70 (2.233.26)

Maternal age** (years) ,20 2.86 (2.263.63) 2024 1.34 (1.201.50) 2529 1 3034 1.09 (0.971.22) 35 1.18 (0.961.44) Educational level/years of education (employees or students) or unemployment University level/17 1 BA level/1416 1.31 (1.141.51) Vocational training/1113 1.83 (1.602.10) Unskilled/912 2.17 (1.752.70) Unemployed, unspecied 2.14 (1.452.70) educational level Partner Yes 1 No 1.59 (1.252.02) Network (practical/close friend/ economical support) Complete 1 Not complete 1.64 (1.441.86) Family contact frequency Every day 1.33 (1.211.45) Less than every day 1 Size of residence (m2) ,60 1.31 (1.111.56) 60 1 Residential area*** Big cities 1 Small cities/rural 1.25 (1.141.36) Smoking Nonsmoker 1 Occasionally/stopped 1.33 (1.181.50) Smoker 1.90 (1.702.13) Waiting time to pregnancy Not planned 1.47 (1.291.67) ,6 months 1 6 months 1.11 (1.011.22) Infertility treatment**** Yes 1.06 (0.901.25) No 1 Self-rated health Very good 1 Normal/do not know 1.32 (1.211.44) Less good 2.16 (1.722.70) Calendar time, per year 0.97 (0.941.00)

1.50 (1.161.93) 1.04 (0.931.17) 1 1.12 (1.001.26) 1.15 (0.931.42)

1 1.23 (1.061.41) 1.58 (1.371.82) 1.66 (1.332.08) 1.62 (1.351.93)

1 1.11 (0.861.44)

Nonresponders were more often young, unemployed, unskilled and delivered preterm (21 versus 4%). Stratication of the analysis excluding and including nonresponders did not change the results substantially.

1 1.56 (1.371.78) 1.26 (1.151.38) 1 1.27 (1.061.51) 1 1 1.13 (1.031.25) 1 1.27 (1.121.43) 1.56 (1.391.75) 1.23 (1.071.41) 1 1.03 (0.931.14) 1.03 (0.871.22) 1 1 1.23 (1.131.35) 1.83 (1.452.30) 0.98 (0.951.01)

Discussion
We observed that depression and anxiety were signicantly associated with fear of childbirth among nulliparous women. This result is in line with those of a number of studies in which anxiety, depression or low self-esteem was reported to be associated with fear of childbirth.711 In a study of 278 Finnish women of any parity and at low obstetric risk, fear of childbirth was associated with general anxiety and low selfesteem.9 Likewise, in a study of 280 nulliparous women in the USA in their third trimester, low self-esteem and low selfefcacy were associated with a strong fear of childbirth.10 In a Swedish study of 162 women,7 a high correlation was found between fear of childbirth and anxiety. A study of 1321 women in Norway and 951 in Sweden conrmed the nding of an association between general anxiety and fear of childbirth.8,11 Having suffered sexual abuse is also reported to be associated with fear of childbirth.1,11 In the present study, the women were not asked about sexual abuse, but we speculate that the low self-rated health reported by some women may be an indicator of having been subjected to sexual abuse. In addition to the above-mentioned psychological factors, we also observed that the lack of a social network, a low educational level or unemployment and young age were important characteristics associated with fear of childbirth. In contrast, two previous studies did not nd an association with educational level measured in broad categories; however, these studies had small sample sizes.9,10,12

*Variables are from interview I unless otherwise stated. **Calculated from information from the medical birth registry on date of birth of the child and maternal date of birth. ***From The Medical Birth Registry. ****Only asked if time to pregnancy was 6 months. Women with ,6 months to pregnancy were classied as no infertility treatment.

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14,1922

As fear of childbirth has received growing attention,811, we tested whether it increased in Denmark between 1997 and 2003. Contrary to our expectations, we did not observe an increase in the prevalence of fear of childbirth during that period. In previous studies of the period 1981 2004, the prevalence of fear of childbirth was 513%,8,12,19,21 but measurements were not made over time in the same population. It would be logical to assume that fear of childbirth is receiving growing attention because it is increasing; however, it may be that women who fear childbirth have become more likely to speak about the problem and make demands such as for a caesarean section. Although the prevalence of fear of childbirth was similar in both early and late pregnancy, 3.2% of women reported fear at both interviews. We could not ascertain whether changes in their answers between interview I and II were due to changes in individual circumstances. As women who fear childbirth have fewer social and psychological resources and because some women expressed fear only at interview II, we recommend that women be asked about their concerns for their upcoming delivery later in pregnancy, as bringing fear into the daylight could alleviate the fear. Evidence for an effect of specic counselling for fear of childbirth is, however, lacking. Two studies showed that a therapeutic intervention decreased maternal requests for caesarean section, but they did not include a control group.1,23 In the only randomised controlled trial on the subject, no clear effect of an intervention on the fear of childbirth was observed,24 as more than half the women in both the intervention group and the control group changed their request for a caesarean section. This result is in line with our results, which show that only half the women who expressed fear in early pregnancy also expressed fear in late pregnancy. In this study, the women were asked about unspecied fear of childbirth. Like others, we found that general anxiety or depression is highly correlated with fear of childbirth.711,25 Other researchers have found that fear for the childs health and fear of pain are some of the most frequent causes.19 Alehagen et al. suggested that expression of fear of birth pain might be considered a more acceptable way of expressing a general fear of childbirth.26 This is an important clinical issue, as fear of childbirth is often countered by ensuring the possibility of epidural analgesia. The same researchers found that women who expressed fear before delivery and who had epidural analgesia did not have lower levels of fear during delivery.26 This indicates that epidural analgesia alone should not be used to overcome fear of childbirth, as analgesia relieves physical pain but not psychological pain. The advantages of this study include the large sample size, the nationwide coverage of the cohort, our ability to adjust for a number of important confounders and the restriction of the cohort to healthy nulliparous women with a singleton pregnancy. In addition, we included only women who reported

fear of childbirth before any pregnancy complication. The limitations of our study include a participation rate of approximately 30%. A study of selection bias in the DNBC found that participants were less often smokers, tended to be older than 25 years and more often had a body mass index (BMI) between 18.5 and 24.9.16 We would expect that nonparticipants in the DNBC might have had a higher rate of fear of childbirth, which would potentially result in underestimation of the strength of the associations observed. In order to elucidate the possible impact of nonparticipation on the results, a multivariate analysis was conducted with the inclusion of dropouts at interview II who reported a higher level of fear at interview I. The results of this analysis were not, however, substantially different from those of the analysis at interview II (Table 2). The fact that the two interviews in the same women were undertaken by different interviewers could be a source of bias; however, the interviewer effect was tested in a study in the DNBC and little reason was found to believe that the interviewer introduced bias.27

Conclusion
Fear of childbirth in nulliparous women most often occurs among women with few social and psychological resources. In this cohort, the frequency of fear of childbirth was the same in late pregnancy as in early pregnancy. Although half of the women who expressed fear at the early interview did not express fear at the late interview, this effect was counterbalanced by the fact that a similar number of women became fearful between the interviews. An increased focus on fear of childbirth does not seem to be justied by an increase in fear of childbirth, as the prevalence of fear was stable during the study period, 19972003.

Ethical approval
The Danish Data Protection Agency approved the project (No. 2004-41-4747), and the DNBC steering committee granted authorisation for use of data on the cohort (No. 2004-13).

Funding
M.L. was funded by the Health Foundation, the Danish Midwife Association, the Lundbeck Foundation, H:S. Central Research Fund, the Aase and Ejnar Danielsen Foundation and the Linex Foundation. The Danish National Research Foundation established the Danish Epidemiology Science Centre, which initiated and created the DNBC. The cohort is furthermore a result of a major grant from this Foundation. Additional support for the DNBC is obtained from the Pharmacy Foundation, the Egmont Foundation, the March of Dimes Births Defects Foundation, the Augustinus Foundation and the Health Foundation.

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Contributors
M.L. planned the project, M.H. and C.J. advised on the design, M.L. managed the data, performed the statistical analyses and drafted the paper. M.H. and C.J. contributed to the writing of the paper.

Acknowledgements
We thank Visti Birk Larsen for help with data management and Kirsten Frederiksen for statistical advice and for valuable comments on the manuscript. j

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