Abstract

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Fear of childbirth is a universal human phenomenon but in acute form it can aggravate the course of pregnancy and childbirth. The goal of this research is to study experiences of anxiety and fear of childbirth amongst pregnant women in Bulgaria using methods that are comparable to European studies.

Introduction

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The current research is the first of its kind in Bulgaria. The data collected via an author`s inquiry and Wijma`s Questionnaire (W-DEQ – version A) provide reasons to argue that fear of childbirth is a frequent phenomenon. During the research, 2360 pregnant women are studied with average age 27.7 years which corresponds to the profile of the pregnant woman in Bulgaria (27.5 years). The pregnant women who are included in the study are in different pregnancy periods and live in seven major towns in Bulgaria with an overall number of 40722 childbirths for year 2010. Fear of childbirth amongst pregnant women in Bulgaria affects 26% of pregnant women attending women`s consulting and 10% of those visiting courses for prenatal preparation. The analysis of different aspects of fear of childbirth shows that 75% of pregnant women feel dependent on medical specialists and environment in maternity hospitals. The most severe fears in 57.3% of them are related to incompetent medical interventions during childbirth. Health and well-being of the child causes severe fear in 53.2%. Despite those facts, fear of childbirth amongst pregnant women is not a reason for the large number of operative deliveries in recent years.

Methods

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In studying the fears of Bulgarian women related to childbirth we based the research on Klaas Wijma`s method “Delivery Expectancy/Experience Questionnaire” (W-DEQ) version A which would make it possible to show where we stand, compared to other European countries.

Wijma`a “Delivery Expectancy/Experience Questionnaire” (W-DEQ) was developed in the last 10 years. The goal is to create a questionnaire which measures the fear of childbirth with the help of the cognitive assessment of a woman regarding her present delivery.  The instruments are applicable for first-time mothers and for multiparas. W-DEQ is developed to measure fear related to childbirth during pregnancy and after delivery through questions which describe expectations before (version A) and experiences after childbirth (version B).  The substance of fear of childbirth is operationalized by means of statements containing items related to intensity of feelings and cognitions regarding the present delivery. The items are obtained through clinical experience with fear of childbirth.

In filling of W-DEQ a woman is instructed to assess her own personal feelings and perceptions according to a six-level Likert scale. The answers of each question are presented as a scale from 0 to 5 (0 and 5 are the extreme values), which correspond to the two extremes of feelings or thoughts. Women are instructed to answer every question by circling the figure which most precisely corresponds to how they imagine their delivery will pass. They answer spontaneously by crossing or circling 33 questions.

A six-level scale is chosen because reliability increases when the number of levels in the scale increases. The usage of a six-level scale is adopted, instead of a seven-level scale, in order to avoid an answering style with neutral answers which may cause a loss of variance. The minimal result is 0 and the maximal result is 165. If the result is higher, the manifested fear of childbirth is more severe. Regarding the formulation of items number 2, 3, 6, 7, 8, 11, 12, 15, 19, 20, 24, 25, 27, 31 their answers, which are positively formulated, have to be reversed for the calculation of the individual total result.

The procedure of using the questionnaire includes a translation of the questionnaire in Bulgarian language. The standard translation procedure stipulates the following consecutive steps which were abided: a translation from the original (English) language to Bulgarian by two independent experts. These translations were coordinated with an authorized translator of Medical University – Varna. As a result, a version of Wijma`s “Delivery Expectancy/ Experience Questionnaire” (W-DEQ) was approved which preserves the essence and the meaning of the statements in the original.

Results

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According to the psychometric research via W-DEQ, the Bulgarian woman is most often afraid that she will be “not at all independent” during labor and delivery. This is determined by the totalitarian model of conducting the birthing process in our maternity clinics where behavior is “appointed” only and exclusively by a medical team. On second place is uneasiness as a cognition which would accompany the birthing process. This quite naturally corresponds with a feeling of tension and on fourth place is the fear of pain during labor and delivery. Expectations towards childbirth could be formulated as negative, related to pain, fear, tension and lack of control over the situation. The common expectancy that childbirth will be “not at all fantastic” is ranged on fifth position, followed by the fear that the pregnant woman will not be able to control herself in the course of the birth process. The results of the conducted research via “Delivery Expectancy/Experience Questionnaire” (W-DEQ) version A are shown in Table 1. The results are displayed in a descending order, ranged by total average result. The numbers and the contents of the statements (items) used in the questionnaire are also shown.

See Illustration

Analysis of results: Our research shows that pregnant women feel dependent on medical specialists and environment in maternity hospitals. Expectations of experiencing pain evaluated via the W-DEQ method are on fourth place. This suggests that despite the entering of anesthesiology in maternity wards, no alternatives are offered to pregnant women. As an analogy, in Table 3 we show comparative data between Bulgarian women and a study conducted in Sweden in 2001 using the same methods. It can be seen that fear of pain in the Swedish research is not at all present in the first ten experiences related to childbirth. It is clear from the analysis of the study that lack of self-confidence, expectancy that she will be afraid and she will experience panic during labor and delivery are equally assessed by Bulgarian and Swedish women.

See Illustration

The most severe fear is declared towards dimension “dependency” on medical team during labor and delivery. Traditionally, in our country, the delivery is conducted in health institutions under the care of large team of obstetricians, midwifes, pediatricians and anesthesiologists. Despite that, Bulgarian women are most often afraid of being “not at all independent” during labor and delivery. Although all women admitted in maternity institutions sign an informed consent form, those women put in first place their worries and fears related to their own dependency/independency. This is due to the totalitarian model of conducting the birth process in maternity clinics where behavior is being “appointed” by a doctor. Labor and delivery is still directed, although this trend is long ago rejected by the world scientific community. Decisions during birth process are taken only and exclusively by the person directing the delivery. Cases in which those decisions are discussed or explained in details to the pregnant woman and her family are mostly an exception.

Fear related to experiencing dependency on the decisions of the medical team is not present in top ten in studies conducted in Sweden, France and Italy. Expectation for lack of relaxation, tension and pain are negative experiences to which Bulgarian women relate their delivery. The reason for that could be the absence of good communication and the lack of psychic-emotional support of medical specialists involved in labor and delivery. These skills are not stimulated during basic and post-graduate education of medical specialists involved in the birth process. On the other hand, there are still living myths that “a woman giving birth is half-dead” or that “a woman who has never given birth knows nothing”. This creates a legend around childbirth as something extremely hazardous and filled with danger.

Even the introduction of anesthesiology in maternity wards does not decrease fear of pain. That fear is ranged on fourth position in our research and is not present at all in top ten of fears of childbirth announced by women in Scandinavia, France and Italy. Anesthesia of labor and delivery continues to be of one of the leading unsolved problems in the medical community in Bulgaria. And while medication methods are practiced in different clinics depending on the presence of competent anesthesiologists, non-pharmaceutical ways for anesthesia of labor and delivery are disregarded and rarely used. This could be due to lack of knowledge and skepticism of their effect or to unwillingness to put them into practice. These methods cannot be a priority for specialists in maternity wards because they require a long education period. During the comparative analysis of expectancies and experiences via Wijma`s W-DEQ method we proved that similarities in experiences of Bulgarian and Swedish women are the following assumptions: not at all composed, extreme panic, extremely afraid.  And while women giving birth in Sweden are afraid that they will not be strong enough, pregnant women in Bulgaria are worried that they will be dependent and that delivery will not be fantastic. Besides the fear of pain and the feeling that they are not in control, the expectations of the two groups are similar in regard of uneasiness, fear and panic.

References

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2.  Areskog, B., Uddenberg, N., Kjessler, B.Experience of delivery in women with and without antenatal fear of childbirth. Gynecologic and Obstetric Investigation, 16(1), 1983.
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4. Eriksson, C.,  Westman, G., Hamberg, K. Experiential factors associated with childbirth-related fear in Swedish women and men: A population based study. Journal of psychosomatic obstetrics and gynecology, 26 (1), 2005.
5.  Eriksson, C., Westman, G., Hamberg, H., Content of childbirth-related fear in Swedish women and men - Analysis of an open-ended question. Journal of midwifery and womens health. 51 (2), 2006.
6. Wijma, K., Wijma, B., Zar., M. Psychometric aspects of the W-DEQ; a new questionnaire for the measurement of fear of childbirth. Journal of psychosomatic obstetrics and gynecology, 19 (2), 1998.
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8. Wijma, K. Why focus on 'fear of childbirth'? Journal of psychosomatic obstetrics and gynecology, 24 (3), 2003.

Source(s) of Funding

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None

Competing Interests

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None

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