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Childhood Abuse and Fear of Childbirth A Population-based Study

l Mirjam Lukasse, MSc, Siri Vangen, MD, PhD, Pa ian, MD, PhD, Merethe Kumle, MD, PhD, Elsa Lena Ryding, MD, PhD, and Berit Schei, MD, PhD, on behalf of the Bidens Study Group*
ABSTRACT: Background: Childhood abuse affects adult health. The objective of this study

was to examine the association between a self-reported history of childhood abuse and fear of childbirth. Methods: A population-based, cross-sectional study was conducted of 2,365 pregnant women at ve obstetrical departments in Norway. We measured childhood abuse using the Norvold Abuse Questionnaire and fear of childbirth using the Wijma Delivery Expectancy Questionnaire. Severe fear of childbirth was dened as a Wijma Delivery Expectancy Questionnaire score of 85. Results: Of all women, 566 (23.9%) had experienced any childhood abuse, 257 (10.9%) had experienced emotional abuse, 260 (11%) physical abuse, and 290 (12.3%) sexual abuse. Women with a history of childhood abuse reported severe fear of childbirth signicantly more often than those without a history of childhood abuse, 18 percent versus 10 percent (p = 0.001). The association between a history of childhood abuse and severe fear of childbirth remained signicant after adjustment for confounding factors for primiparas (adjusted OR: 2.00; 95% CI: 1.303.08) but lost its signicance for multiparas (adjusted OR: 1.17; 95% CI: 0.761.80). The factor with the strongest association with severe fear of childbirth among multiparas was a negative birth experience (adjusted OR: 5.50; 95% CI: 3.778.01). Conclusions: A history of childhood abuse signicantly increased the risk of experiencing severe fear of childbirth among primiparas. Fear of childbirth among multiparas was most strongly associated with a negative birth experience. (BIRTH 37:4 December 2010) Key words: birth experience, childhood abuse, fear of childbirth

Childhood abuse has an impact on adult health (1). Long-term effects comprise a wide range of physical and psychological symptoms as well as psychiatric and medical diagnoses (1). Psychological symptoms include low self-esteem, poor coping skills, disturbed
Mirjam Lukasse is a Doctoral Student at the University of Troms, Troms, and Research Midwife at the Department of Obstetrics and Gynecology, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Siri Vangen is Senior Researcher at the Norwegian Resource Centre for Womens Health, Rikshospitalet, Oslo Univerl sity Hospital, Oslo, Norway; Pa ian is Professor at the Department of Obstetrics and Gynecology, University Hospital of North Norway and Institute of Clinical Medicine, University of Troms, Troms, Norway; Merethe Kumle is Senior Researcher at the Centre of Randomized Controlled Trials, University Hospital of North Norway, Troms, Norway; Elsa Lena Ryding is Senior Consultant at the Department of Woman and Child Health, Karolinska Institutet, and Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden; and Berit Schei is Professor at the Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, and Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim, Norway.

self-identity, inability to trust, poor interpersonal social skills, and increased vulnerability to stress (2). Neurobiological studies have demonstrated that childhood abuse may alter brain development by programming the stress response system to overreact to
*The members of this study group are listed in the Appendix. The Bidens Study was supported by the Daphne II Program to combat violence against children, young people, and women, European Commission for Freedom, Security and Justice, Brussels, Belgium (grant no. JLS 2006 DAP-1 242 W30-CE-0120887 00-87). The rst author is supported for her Doctorate by the Norwegian Womens Public Health Association, Oslo, Norway. Address correspondence to Mirjam Lukasse, MSc, Oslo University Hospital Rikshospitalet, Department of Obstetrics and Gynecology, Postboks 4950, Nydalen, N-0424 Oslo, Norway.

Accepted March 15, 2010 2010, Copyright the Authors Journal compilation 2010, Wiley Periodicals, Inc.

268 new stressors, thereby increasing vulnerability to anxiety (2,3). Childbirth, for most women, involves physical and mental stress (4). Most of the women cope with the challenges of pregnancy and childbirth, whereas 6 to 13 percent of pregnant women experience severe, disabling fear of childbirth (57). Antenatal fear of childbirth may affect the course and outcome of pregnancy and the experience of childbirth (711). Fear of childbirth increasingly implies a request for elective cesarean (7,8,12). A Norwegian clinical study of women referred because of maternal request for cesarean section as a result of fear of birth, showed that 63 percent had been subjected to abuse (8). A Swedish study among unselected pregnant women found an association between negative experiences of sexuality while growing up and fear of childbirth (13). Psychological characteristics of women fearing vaginal birth include susceptibility to anxiety, neuroticism, vulnerability, depression, low selfesteem, dissatisfaction with the partnership, and lack of social support (14), characteristics notably similar to those describing survivors of childhood abuse (2). On the basis of the literature we hypothesized that women with a history of childhood abuse are more vulnerable to stress and will therefore experience more severe fear of childbirth than women without a history of childhood abuse. The aim of our study was to explore the association between a self-reported history of sexual, physical, and emotional abuse in childhood and fear of childbirth.

BIRTH 37:4 December 2010

Methods We conducted a cross-sectional study among an unselected population of pregnant women at ve obstetric departments in ve cities in Norway: Oslo, Troms, Alesund, Drammen, and Trondheim. The hospitals in Troms, Oslo, and Trondheim are university hospitals and those in Drammen and Alesund are county hospitals. The number of deliveries at these departments ranged from 1,300 to 3,400 births per year. Questionnaires with an information letter and a consent form were sent to pregnant women after they had attended their routine ultrasound examination at 18 weeks gestation. Women requiring treatment because of pathology detected during a routine ultrasound scan and women with insufcient Norwegian language to ll out the questionnaire were excluded from the study. We recruited participants from January 2008 to March 2009. Nonresponders were sent one reminder after 1 month. The response rate varied from 61 percent in Oslo to 44 percent in Alesund, with an overall response rate of 50 percent. A total of 2,429 women returned the questionnaire. We excluded 43

women because of 7 or more missing answers of the 33 items of the Wijma Delivery Expectancy Questionnaire, 6 women because they were younger than 18 years old, and 15 women who failed to complete 2 of the 8 pages of the questionnaire. The nal sample included 2,365 women. Based on our previous study, we estimated the prevalence of severe fear of labor to be 7 percent among women without and 14 percent among women with a history of childhood abuse (15). To detect this difference in prevalence, with 80 percent power and p = 0.05 twosided, we needed 300 women in each group (with and without any childhood abuse). With an estimated prevalence of 20 percent for any childhood abuse, we needed to include 1,500 women in total. The Regional Committee for Medical Research Ethics and the Norwegian Data Inspectorate approved the study. This cross-sectional study in Norway is part of a multinational cohort study, the Bidens Study, conducted in six European countries. Bidens is the acronym for the six participating countries, Belgium, Iceland, Denmark, Estonia, Norway, and Sweden. The questionnaire included the Norvold Abuse Questionnaire, a validated instrument measuring emotional, sexual, and physical abuse (Table 1) (16). Childhood abuse was dened as abuse before the 18th birthday. The question measuring mild physical abuse was excluded from our analyses because it showed low specicity, as noted previously (16). Any childhood abuse included any type of childhood abuse at any level of severity. Fear of childbirth was measured using the Wijma Delivery Expectancy Questionnaire version A, designed to measure fear of childbirth by means of womens cognitive appraisal during pregnancy of the coming delivery (17). The questionnaire has 33 items, which can be scored from 0 to 5. The sum score theoretically ranges from 0 to 165: the higher the score is, the greater the fear of childbirth. A sum score of 85 or more is considered to represent severe fear of childbirth, whereas a sum score of 100 or more is the cutoff level for extreme fear of childbirth (9,18). Depression was measured using a short-matrix version of the Edinburgh Depression Scale (EDS-5), which consists of ve questions (19). The scoring of each question ranges from 0 to 3, with 0 for the absence of symptoms and 3 for maximum severity of symptoms. A sum score of 7 or higher is considered to reect moderate symptoms of depression (19). Women were asked to describe the experience of their rst and last births by ticking off one of the following options: 1) purely positive experience; 2) mainly positive experience with negative elements; 3) mainly negative experience with positive elements; and 4) purely negative experience. These variables were dichotomized into a negative or

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269

Emotional total: 257

Emotional alone: 98

67

Physical alone: 111

Physical total: 260

43 49 39

Sexual alone: 159

Sexual total: 290

Fig. 1. Childhood abuse (n = 566), types and overlapping categories, in the Norwegian Bidens study population (n = 2,365), study period 20082009. positive birth experience. When two experiences were reported, the last birth experience was chosen. Eleven percent of the study sample had 1 to 6 missing values of the 33 items of the Wijma Delivery Expectancy Questionnaire. Most women, 188 (7.9%), lacked only one item. Missing values (6 items) were replaced by the series mean. Cases with missing values for the other variables were excluded from logistic regression analyses. Adjusted multiple logistic regression was used to estimate odds ratios (OR) and 95 percent condence intervals (CIs) for the association of any childhood abuse and severe childhood abuse for primiparas and multiparas separately. We adjusted for the a priori selected potential

Data Analysis Statistical analyses were performed using the Student t tests and one-way ANOVA when appropriate and chi-square test or Fishers exact test for categorical variables. Internal reliability for Wijma Delivery Expectancy Questionnaire was high (Cronbachs a = 0.92).

Table 1. The Norvold Abuse Questionnaire for Emotional, Physical, and Sexual Abuse

Level of Severity
Emotional Mild Moderate Severe Physical Mild Moderate Severe Sexual Mild, no genital contact Mild, humiliation

Type of Abuse
Have you experienced anybody systematically and for a long period trying to repress, degrade, or humiliate you? Have you experienced anybody systematically and by threat or force trying to limit your contacts with others or totally control what you may and may not do? Have you experienced living in fear because somebody systematically and for a long period has threatened you or someone close to you? Have you experienced anybody hitting you, smacking your face, or holding you rmly against your will? Have you experienced anybody hitting you with his st(s) or with a hard object, kicking you, pushing you violently, giving you a beating, thrashing you, or doing anything similar to you? Have you experienced anybody threatening your life by, for instance, trying to strangle you, showing a weapon or knife, or by any other similar act? Has anybody against your will touched parts of your body other than the genitals in a sexual way or forced you to touch parts of his or her body in a sexual way? Have you in any other way been sexually humiliated; e.g., by being forced to watch a pornographic lm or similar against your will, forced to participate in a pornographic lm, or similar, forced to show your body naked, or forced to watch when somebody else showed his her body naked? Has anybody against your will touched your genitals, used your body to satisfy himself herself sexually, or forced you to touch anybody elses genitals? Has anybody against your will put or tried to put his penis into your vagina, mouth, or rectum, put or tried to put an object or other part of the body into your vagina, mouth, or rectum?

Moderate, genital contact Severe, penetration

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Table 2. Characteristics of Women with and without a History of Childhood Abuse in the Norwegian Bidens Study Population (n = 2,365), Study Period 20082009

Any Childhood Abuse No (n = 1,799) Sociodemographic and Risk-Behavior Variables

Age (yr) 1824 2530 3135 36 Education Primary Secondary Higher, <4 yr Higher, 4 yr Missing Occupation Employed Student Not employed Missing Parity Primiparous Multiparous Last birth experience Positive Negative Missing Depressive symptoms EDS score < 7 EDS score 7 Missing Adult abuse Yes No Missing

Yes (n = 566) No. (%)

94 (16.6) 216 (38.2) 180 (31.8) 76 (13.4) 23 (4.1) 195 (34.5) 157 (27.7) 189 (33.4) 2 (0.4) 463 (81.8) 46 (8.1) 55 (9.7) 2 (0.4) 247 (43.6) 319 (56.4) 241 (75.5) 77 (24.1) 1 (0.3) 469 (82.9) 86 (15.2) 11 (1.9) 219 (38.7) 334 (59.0) 13 (2.3)

Total (n = 2,365) No. (%)

269 (11.4) 893 (37.8) 920 (38.9) 238 (12.0) 52 (2.2) 596 (25.2) 733 (31.0) 971 (41.1) 13 (0.5) 2,079 (87.9) 159 (6.7) 122 (5.2) 5 (0.2) 1,034 (43.7) 1,331 (56.3) 1,046 (78.6) 281 (21.1) 4 (0.3) 2,146 (90.8) 173 (7.3) 46 (1.9) 530 (22.4) 1,795 (75.9) 40 (1.7)

No. (%)
175 (9.7) 677 (37.6) 740 (41.1) 207 (11.5) 29 (1.6) 401 (22.3) 576 (32.0) 782 (43.5) 11 (0.6) 1,616 (89.8) 113 (6.3) 67 (3.7) 3 (0.2) 787 (43.7) 1,012 (56.3) 805 (79.5) 204 (20.2) 3 (0.3) 1,677 (93.3) 87 (4.8) 35 (1.9) 311 (17.3) 1,461 (81.2) 27 (1.5)

v2 test; p*
<0.001

<0.001

<0.001

0.964

0.128

<0.001

<0.001

*Comparing groups of women with and without childhood abuse; multiparas only. EDS = Edinburgh Depression Scale-5.

confounders of age, education, civil status, planned pregnancy, adult abuse, and depressive symptoms. Negative birth experience was added in the analyses for multiparas only. We explored the effect of the different confounding factors on the association between any childhood abuse and severe fear of childbirth for multiparas by constructing a different regression model for each confounding variable. All analyses were two-sided at a = 0.05. The statistical software package SPSS 15.0 was used for all data analyses (20).

Results Of all women, 566 (23.9%) had experienced any childhood abuse, 257 (10.9%) emotional abuse, 260 (11%)

physical abuse, and 290 (12.3%) sexual abuse. We found a substantial overlap among the different types of abuse (Fig. 1). Among women reporting childhood abuse, 35 percent had been exposed to two or more types of abuse. Primiparas were just as likely as multiparas to report childhood abuse, 23.9 versus 24.0 percent. Nine percent of women with a history of childhood abuse did not have Norwegian as their language of birth compared with 6 percent of women without a history of childhood abuse (p = 0.040). Less childhood-abused women lived with a partner (93.5%) compared with nonchildhood-abused women (96.8%; p < 0.001). Fewer childhood-abused women had planned their pregnancy (70.5%) compared with nonchildhood-abused women (81.4%; p < 0.001). Other characteristics and comparisons of abused and nonabused groups are shown in Table 2.

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Table 3. Unadjusted Odds Ratios for Severe Fear of Childbirth for Different Categories of Self-Reported Childhood Abuse Among Primiparous and Multiparous Women in the Norwegian Bidens Study Population (n = 2,365), Study Period 20082009

Primiparas with Severe Fear of Childbirth (n = 131 1,034) Type of Childhood Abuse
Sexual Mild, no genital contact Mild, humiliation Moderate, genital contact Severe, penetration Physical Moderate, physical Severe, physical Emotional Mild, emotional Moderate, emotional Severe, emotional Any abuse Physical and sexual Sexual and emotional Physical and emotional Physical, sexual, and emotional

Multiparas with Severe Fear of Childbirth (n = 149 1,331) OR

1.33 1.80 2.35 1.65 1.73 1.78 1.73 2.67 1.78 1.75 1.94 1.84 1.50 1.81 1.80 2.01 1.76

OR
1.91 1.98 1.30 1.84 3.45 3.06 3.07 2.36 3.49 3.66 4.09 2.95 2.48 3.15 4.04 3.96 5.30

95% CI
1.123.27 1.103.62 0.384.45 0.973.50 1.667.17 1.914.90 1.875.03 1.005.60 2.175.49 2.216.06 2.247.48 1.515.76 1.703.64 1.426.95 1.978.30 2.147.33 2.0313.86

95% CI
0.822.17 1.103.00 1.055.27 0.982.77 0.853.51 1.102.91 1.012.94 1.285.58 1.102.91 1.042.94 0.914.10 0.903.74 1.022.16 0.823.78 0.863.80 0.984.10 0.605.26

*Reference group for all analysis is women with no childhood abuse.

The mean Wijma Delivery Expectancy Questionnaire score for women with a history of any childhood abuse was 60.96 (SD: 24.52) compared with 56.57 (SD: 21.84) for women not reporting childhood abuse (p < 0.001). Women with a history of childhood abuse signicantly more often reported severe fear of childbirth (85 on this questionnaire) compared with those without a history of childhood abuse, 18 versus 10 percent (p < 0.001), and extreme fear of childbirth (100 on this questionnaire), 5.7 versus 3.2 percent (p = 0.008). We found a graded response between fear of childbirth and the number of types of abuse women had experienced. The mean Wijma Delivery Expectancy Questionnaire score for women reporting no childhood abuse was 56.57 (SD: 21.83), compared with 59.29 (SD: 23.03) for women reporting one type of childhood abuse, 62.97 (SD: 27.57) for two types, and 67.59 (SD: 22.98) for three types (p = 0.001). We analyzed the association between childhood abuse and severe fear of childbirth at different levels of severity (mild, moderate, and severe) for each type of abuse for primiparas and multiparas separately. We did not observe a graded response corresponding with the level of severity (Table 3). Emotional abuse showed the overall strongest association with severe fear of childbirth for both primiparas and multiparas (Table 3). A history of any childhood abuse remained a signicant risk factor for experiencing severe fear of childbirth

for primiparas also after adjusting for confounding factors (OR: 2.00; 95% CI: 1.303.08) (Table 4). Multiparas showed no association between a history of any childhood abuse and severe fear of childbirth after adjusting for confounding factors (OR: 1.17; 95% CI: 0.761.80) (Table 4). We performed regression models for multiparas, testing the individual effect of each confounding factor on the association between any childhood abuse and severe fear of childbirth. Each of the following confounding factors singularly caused the signicant association to disappear: depressive symptoms, education, adult abuse, or a negative birth experience. For multiparas, fear of childbirth was related to a negative birth experience (Table 5). Multiparas with a negative birth experience were more likely to score signicantly over the mean Wijma Delivery Expectancy Questionnaire score for women with a positive birth experience and no childhood abuse (OR: 5.87; 95% CI: 3.1910.84), for women with any childhood abuse and negative birth experience (OR: 8.95; 5.7214.01), and for women with no childhood abuse and a negative birth experience.

Discussion About one in four women experienced abuse in childhood in our study. Our hypothesis that women with a

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Table 4. Crude and Adjusted Odds Ratios for Severe Fear of Childbirth for Any Childhood Abuse for Primiparas and Multiparas in the Norwegian Bidens Study Population (n = 2,365), Study Period 20082009

Primiparas with Severe Fear of Labor (n = 131 1,034) Characteristics and Risk Factors No. Crude OR
1 2.48 1.37 1 1.42 0.51 0.98 1 5.17 1 0.80 0.93

Multiparas with Severe Fear of Labor (n = 149 1,331) 95% CI

Reference 1.303.08 0.471.54 Reference 1.042.65 0.151.33 0.140.95 Reference 2.2016.85 Reference 0.551.64 0.591.83

95% CI
Reference 1.703.64 0.852.21 Reference 0.922.19 0.181.46 0.462.11 Reference 2.0912.76 Reference 0.491.33 0.581.50

Adjusted OR*
1 2.00 0.85 1 1.66 0.44 0.36 1 6.09 1 0.95 1.04

No.
103 46 9 43 76 21 4 145 4 65 32 46

Crude OR
1 1.50 1.48 1 1.11 0.90 1.23 1 0.70 1 0.40 0.40

95% CI
Reference 1.022.16 0.683.21 Reference 0.741.64 0.521.55 0.423.56 Reference 0.232.08 Reference 0.250.62 0.260.59

Adjusted OR
1 1.17 0.99 1 1.52 1.18 0.67 1 0.39 1 0.44 0.42

95% CI
Reference 0.761.80 0.412.43 Reference 0.972.37 0.642.19 0.202.23 Reference 0.101.48 Reference 0.270.71 0.260.66

Any childhood abuse No 78 Yes 53 Age (yr) 24 31 2530 55 3135 41 36 4 Living with partner No 8 Yes 123 Education Primary 10 Secondary 32 37 <4 yr college university 4 yr college 50 university Planned pregnancy No 44 Yes 87 Adult abuse No 92 Yes 39 Moderate depressive symptoms No 103 Yes 26 Negative birth experience No Yes

1.98 1 1 1.71

1.332.94 Reference Reference 1.142.58

1.87 1 1 1.30

1.163.01 Reference Reference 0.822.05

36 113 102 47

1.26 1 1 1.59

0.851.89 Reference Reference 1.102.31

1.05 1 1 1.10

0.661.67 Reference Reference 0.721.68

1 4.69

Reference 2.787.92

1 3.93

Reference 2.216.99

117 28 67 81

1 3.52 1 5.92

Reference 2.195.67 Reference 4.148.46

1 2.54 1 5.50

Reference 1.474.40 Reference 3.778.01

*Adjusted for all variables in the table except negative birth experience as primiparas do not have a birth experience; adjusted for all variables in the table.

Table 5. Multiparas (n = 1,331) and Fear of Childbirth by History of Any Childhood Abuse and Birth Experience in the Norwegian Bidens Study Population (n = 2,365), Study Period 20082009

Wijma Delivery Expectancy Questionnaire Score Category of Childhood Abuse and Birth Experience
No childhood abuse and positive experience Any childhood abuse and positive experience Any childhood abuse and negative experience No childhood abuse and negative experience

No.
805 241 77 204

Mean (SD)
49.52 (21.10) 52.13 (23.04) 72.48 (24.50) 74.72 (20.35)

OR (95% CI)
1 1.20 (0.901.60) 5.87 (3.1910.84) 8.95 (5.7214.01)

history of childhood abuse are more likely to experience severe fear of childbirth than women without a history of childhood abuse was conrmed for primiparas.

Among multiparas severe fear of childbirth was most strongly associated with a negative birth experience, whereas the association with a history of any childhood

BIRTH 37:4 December 2010

273 specify if this was adult or childhood abuse, or whether it was emotional, physical, or sexual abuse (8). However, a Swedish study from the early 1980s, investigating different background factors for fear of delivery, found a signicant association between fear of delivery and negative experiences during childhood and of sexuality while growing up among primiparas but not among multiparas (13). Our study results are in agreement with the ndings of these studies even though comparison is difcult. We found no graded association between the level of severity for the different types of abuse and severe fear of childbirth, which could be a result of the small numbers (i.e., type II error). The more severe the abuse was, the fewer women reported experiencing it. Another option is that these levels describe severity from the researchers point of view and not the victims. The strongest association we found was between a history of childhood emotional abuse and fear of childbirth. Recent studies suggest that childhood emotional abuse more likely contributes to the development of a cognitive vulnerability to depression than either childhood physical or sexual abuse, because with emotional abuse the depressive cognitions are directly supplied to the child by the abuser (23). Women subjected to emotional abuse may therefore develop an understanding about themselves as being unable to perform well. This perception may lead them to cognitively appraise an approaching birth as a situation they will not manage (well), resulting in a high Wijma Delivery Expectancy Questionnaire score. Our results correspond with other studies, showing that fear of childbirth in multiparous women is primarily related to previous birth experiences (12,24). In our study, multiparous women with a history of childhood abuse were just as likely to report a negative birth experience as women without a history of childhood abuse. The most common reason for women to request birth by elective cesarean section is fear of childbirth (25). Health professionals who offer counseling to women anxious about childbirth should be aware that a history of childhood abuse is an important risk factor for severe fear of childbirth during pregnancy for primiparous women. This knowledge may alter the approach and content of the counseling offered, especially to primiparas presenting with severe fear of childbirth.

abuse lost signicance when other factors were entered into the regression analyses. This population-based study was conducted at ve public obstetric departments among nonselected pregnant women in different regions in Norway. The poor response rate causes some concern about selection bias, that is, the inclusion (or failure) of individuals to participate in a study, which may affect estimates that differ from the estimates based on the entire population. Our study population was similar to the population of women who gave birth in Norway in 2008 (21) when comparing average age (30.6; SD 4.9 vs 30.2, SD 5.3) and proportion of primiparas (43.7% vs 42.8%). Compared with national statistics (21), more women living with a partner took part in our study (90.9% vs 96.0%). This nding could mean that women with any childhood abuse are underrepresented in our study because women who report any childhood abuse are less likely to live with a partner. However, the high prevalence of any childhood abuse in our study suggests that these women did not decline to answer the questionnaire. Even though prevalence of exposure and disease may be different from what is found in the total population, the estimate of the association can still be valid. In contrast to many other studies, our study included physical and emotional abuse as well as sexual abuse. We used validated instruments measuring both childhood abuse and fear of childbirth, which facilitates comparisons with other studies and populations. Age at onset, length of time and frequency of the abuse, and other adverse childhood exposures are factors that might inuence associations. Information about these factors was not available in our study, and therefore their impact could not be assessed. The retrospective reporting of abuse could be subject to recall bias. Women were asked to recall childhood experiences before 18 years of age, when they were on average 30 years old. Our crosssectional design provides associations and not causal relations. However, because we included women after their 18th birthday, they all experienced the abuse before their rst pregnancy. The prevalence of childhood abuse was higher in our current study than in another recent Norwegian study with a larger but similar pregnant population (15). However, studies focusing on abuse, like ours, are known for higher prevalence rates compared with surveys designed with a broader purpose that only include a couple of questions on abuse (22). Few other studies have investigated the association between a history of childhood abuse and severe fear of childbirth. A Norwegian clinical study, including women who expressed a wish for birth by cesarean section because of fear of childbirth, reported that 63 percent of the women had experienced abuse. They did not

Conclusions A history of childhood abuse signicantly increased the risk of experiencing severe fear of childbirth among primiparas. Fear of childbirth among multiparas was most strongly associated with a negative birth experience.

274 References
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Appendix On behalf of the Bidens study group: Berit Schei (principal investigator), University of Trondheim, Norway; Elsa Lena Ryding (co-principal investigator), Karolinska University Hospital, Sweden; Mirjam Lukasse (coordinator), University of Troms, Norway. Local principal investigators include: Marleen Temmerman (University of Ghent, Belgium), Thora Steingrmsdottir (Landspitali University Hospital, Iceland), Ann Tabor (Rigshospitalet, Denmark), and Helle Karro (University Hospital Tallinn, Estonia). Local coordinators include: An-Soe Van Parys (University of Ghent, Belgium), Hildur Kristjansdottir (Iceland), Anne-Mette Schroll (Rigs hospitalet, Denmark), and Anne-Marie Wangel (Malmo University, Sweden).

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