Push past your fear of giving birth

Impending childbirth is a scary prospect, even for women who have already "been there, done that". Psychologist Dr Melanie Woodfield discusses how you can prepare yourself emotionally for labour, and cope with your fear.

We all spend time preparing practically for birth - poring over lists of recommendations of what to take to hospital, packing bags, and later unpacking all of the items we were sure would be useful but never made it out of the suitcase! But how much time do we spend preparing mentally and emotionally? For many women, this emotional preparation will involve coping with a degree of fear about the impending labour.

While most women eagerly await the birth of their child, fear of childbirth is very common. In fact, in a 2007 survey of 300 pregnant women in Hong Kong by Tsui and colleagues, all of the surveyed women reported some degree of fear, and 22% of the women had considered requesting an elective caesarean due to the extent of their fear of labour!

Fear can also influence pain relief choices - a study by Heinze and Sleigh in 2003 found that women who chose to deliver with epidural pain relief tended to have a high-level of fear of childbirth. 

In extreme cases, this profound fear of childbirth (often despite desperately wanting a baby) is known as tokophobia. This condition, while first formally described by Kristina Hofberg and Ian Brockington in 2000, is not new. Various authors have written both helpful and unhelpful comments about childbirth fear for many years - consider Jones' 1942 comment: "In labour, the woman's true character is revealed. If it is harmonious and loving, all goes well. If it contains conflicting elements of hate, resentment, envy, and fear, then they reflect themselves in disturbances of the labour process."  

Various studies have examined exactly what pregnant women are afraid of, and the origins of these fears are not surprising. In Tsui's 2007 study, women identified that a powerful contributor to their fear of childbirth was "negative stories". Have you ever noticed that movies and television often portray labour as intensely loud, sweaty, long, and very painful? And the stories we hear circulating when mothers get together are usually horror stories of difficult births. We don't often hear stories of straightforward and easy births, despite many such births occurring every day! Also, those negative stories tend to stick in our minds more readily.

In 2006, Colleen Fisher and her colleagues carried out in-depth interviews with 22 Australian women to investigate themes of women's fear of childbirth. They agreed that "horror stories" were an important contributor to fear, and also identified factors such as fear of the unknown, fear for the wellbeing of the baby, fear of pain, losing control and disempowerment, and the uniqueness (and unpredictability) of each birth. 

For women who had given birth previously, "previous horror birth" and "speed of birth" were the two factors most strongly contributing to fear of future deliveries. In a large study of more than 8,000 pregnant women, by Geissbuehler and Eberhard in Switzerland, fear for the child's health and fear of pain were the most frequently mentioned concerns. Carola Eriksson and her colleagues surveyed 410 women in Sweden in 2005 and found that "exposedness and inferiority" was the key factor contributing to women's fear of childbirth, suggesting possible slight cultural differences in exactly what contributes to fear.

In Colleen Fisher and her colleagues' study, two central factors emerged as helping to reduce fear of childbirth:  Positive relationships with midwives, and the support women receive from their social network. education, such as attending antenatal classes, can also help to reduce anxiety.

An intervention that has been shown time and time again to assist with fear (and anxiety in general) is Cognitive Behavioural Therapy, also known as CBT. In a nutshell, CBT proposes that how we think and feel about an event, such as labour, has a significant effect on how we experience that event. Psychologists like Aaron Beck have devoted their careers to studying the relationships between our thoughts, feelings, and behaviour, and have concluded that these factors are powerfully interrelated. Beck proposed a "five-part model" to understand this relationship:
•  Thoughts. Both what is running through our mind at the time ("automatic thoughts") and the deeper beliefs ("core beliefs") that drive our thinking patterns. Examples:  "I can't do this, it hurts too much!" or "I am a strong, powerful woman."
•  Emotions. How we feel, which can vary widely from moment to moment. Examples: worried, angry, excited, scared.
•  Physiology. The processes that occur within our bodies. Examples: increased heart rate, blood pressure, sweating, breathing rapidly.
•  Behaviour. What we do. Examples: Shouting, sitting, lying down, walking, talking. Some psychologists even assert that thinking is a behaviour!
•  Environment. The characteristics of the surroundings we're in. Not only the physical aspects, but the social and emotional aspects too. Examples: Living room vs hospital room, partner present vs partner absent, busy vs quiet, partner anxious vs partner calm.

If we're thinking and feeling a certain way, this can lead to us doing certain things, which changes what's happening in our bodies and how we interact with our environment. Consider the following example:
Sarah, a first-time mum, is in early labour. Sarah's mother has repeatedly told her how painful labour is and Sarah has been dreading labour since before she became pregnant. She thinks that she won't be able to cope (thought) and is petrified (emotion) that she will pass out and possibly die. Sarah finds herself panicking when she feels the first contractions. She starts to hyperventilate (body) and feels faint. Sarah tells herself that this means that her worst fear is beginning to come true and stands up (behaviour), breathing rapidly. Her partner, worried for Sarah, is talking very quickly, trying to calm her, and demanding, "Are you okay?" loudly and repeatedly (environment). Sarah faints. Her worst fears are realised, and, when she is revived, her LMC assesses that the baby is in distress and Sarah requires an emergency Caesarean. 

How we think and feel about a situation can start, or contribute to, a chain of events that can have unwanted consequences. The good news is that changing one aspect (usually how we think) can have a profound effect on the other factors. Consider this alternative scenario:
When Sarah feels the first contractions, she feels a flash of panic and thinks, "Oh no, this is it!" She feels the old familiar thoughts come rushing in, but instead of allowing them to overwhelm her, she concentrates on breathing slowly, and asks her partner to bring her a document she had spent a lot of time thinking about and preparing. She slowly and carefully reads this paper repeatedly over the next few hours, and her partner and LMC calmly remind her of the statements written there. Sarah feels the pain of labour, but she doesn't feel overwhelmed.
While it seems like all Sarah was doing in the second scenario was "thinking positively", challenging unhelpful thoughts with balanced or adaptive thoughts is more than simply thinking positively. Adaptive thoughts are honest and truthful, but balanced. For example:
•  Negative thought: "This is the most painful thing I've ever felt."
•  Thinking positively: "I feel great - can't feel a thing."
•  Balanced thinking: "This hurts, but it is temporary, and I am strong." 
Spending time carefully preparing a document with coping statements or adaptive thoughts, as Sarah did in the second example, can pay huge dividends in reduced anxiety during labour. These statements will be different for every woman, and may include Bible verses, affirmations, poetry, or pieces of advice that have meaning. For example:
•  The average length of first labour is 12-14 hours, so no matter how painful it is, it will be over soon.
•  Every contraction is another step closer to the end.
•  I am young, big, strong, and built for this.
•  As much as it hurts, it is normal, familiar, useful pain, which will not kill me or the baby.
•  As contractions get more intense, they're getting more efficient.
•  60,470 babies were born in new Zealand in the year ending March 2007 (approximately 166 per day), and among all those women, there were bound to be people more scared/in pain/more panicked than me, and they did it!
•  Many women have more than one baby, so it can't be too bad if they choose to go through it again.
It is very important to expect that your carefully considered adaptive thoughts and coping statements will be challenged! For most women, labour is a physically and emotionally demanding time. Also, factors outside of your control, such as the need for medical intervention, can be unexpected and frightening. 
Again, coping with these events is likely to be enhanced by good preparation, such as learning about common medical procedures from classes, books, or the internet. Incorporate the possibility of a "plan B" birth into your thinking - the old adage of hoping for the best but preparing for the worst.

In some cases, particularly following difficult births, an anxiety disorder develops in between 1-3% of women. Known as Post-traumatic Stress Disorder (PTSD), symptoms include distressing memories, flashbacks, avoidance of cues or reminders of childbirth, nightmares, irritability and sleeping difficulties. According to a study by Johan Soderquist and his colleagues, factors that increase the likelihood of PTSD developing include depression during pregnancy, severe fear of childbirth, extreme stress during pregnancy, and previous mental health issues. If you are concerned about possible PTSD, talk to your LMC or GP who can put you in touch with your local maternal mental health service. 

Dr Melanie Woodfield is a child and adolescent clinical psychologist in Auckland.

 References

•   Eriksson, Carola,;Westman, Goran; and Hamberg, Katarina. "Experiential factors associated with childbirth-related fear in Swedish women and men: a population-based study." Journal of Psychosomatic Obstetrics & Gynaecology 26.1 (Mar 2005): 63-72.
•   Fisher, Colleen; Hauck, Yvonne; and Fenwick, Jenny. "How social context impacts on women's fears of childbirth: a Western Australian example." Social Science & Medicine 63.1 (Jul 2006): 64-75.
•   Geissbuehler, V and Eberhard, J. "Fear of childbirth during pregnancy: a study of more than 8000 pregnant women." Journal of Psychosomatic Obstetrics & Gynaecology 23.4 (Dec 2002): 229-35.
•   Heinze, SD and Sleigh, Mary J. "Epidural or no epidural anaesthesia: relationships between beliefs about childbirth and pain control choices." Journal of Reproductive and Infant Psychology 21.4 (nov 2003): 323-33.
•   Hofberg, Kristina and Brockington, Ian. "Tokophobia: an unreasoning dread of childbirth. a series of 26 cases." British Journal of Psychiatry 176 (Jan 2000): 83-85.
•   Soderquist, Johan; Wijma, Barbro; and Wijma, Klaas. "The longitudinal course of post-traumatic stress after childbirth." Journal of Psychosomatic Obstetrics & Gynaecology 27.2 (Jun 2006): 113-19.
•   Tsui, Michelle H; Pang, Man W; Melender, Hanna-Leena; Xu, L; Lau, Tze K; and Leung, Tse n. "Maternal fear associated with pregnancy and childbirth in Hong Kong chinese women." Women & Health 44.4 (2007): 79-92.