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Research Article
The Relationship between Fear of Childbirth and Women’s
Knowledge about Painless Childbirth
Mehmet Aksoy,1Ayse Nur Aksoy,2Aysenur Dostbil,1Mine Gursac Celik,1and Ilker Ince1
1Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, 25240 Erzurum, Turkey
2Department of Obstetrics and Gynaecology, Nenehatun Hospital, 25070 Erzurum, Turkey
Correspondence should be addressed to Mehmet Aksoy; drmaksoy@hotmail.com
Received March ; Accepted August ; Published November
Academic Editor: Curt W. Burger
Copyright © Mehmet Aksoy et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
is study investigated the association between fear of childbirth (FOC) and women’s knowledge about painless childbirth
methods. e study was performed on multiparous women within the last month of pregnancy. Data was obtained through a
questionnaire including the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) Turkish form A. FOC was dened as
W-DEQ sum score ≥. Women were questioned about their knowledge about painless childbirth and the most important source of
this knowledge. Group consists of participants with knowledge about painless childbirth. Group consists of participants without
knowledge about painless childbirth. Five hundred and twenty-four women (.%) had knowledge while women (.%) had
no knowledge about painless childbirth. Mean W-DEQ scores in group (68.46 ± 12.53)werefoundtobelowerthangroup
(71.35 ± 12.28)(𝑃 = 0.001). FOC was associated with increased maternal request for elective caesarean section (OR ., % CI
.–.). Better informed pregnant women about painless childbirth methods may reduce the number of women with FOC and
the rate of preferred elective caesarean section.
1. Introduction
Fearofchildbirth(FOC)isaseriousproblemforwomen,
since it leads to avoidance of pregnancy, maternal and fetal
stress, and an increase in maternal requests for cesarean
section []. Some studies have been conducted to investigate
the causes of this fear [,]. Størksen et al. []foundastrong
association between a previous subjectively negative birth
experience and FOC. Sluijs et al. []showedthatfearlevels
were higher in nulliparous women compared to multiparous
women.
Normal vaginal birth for women is a painful event due
to uterine contractions, recurrent vaginal examinations, and
vaginal lacerations. For most women, childbirth is associated
with very severe pain. e perceived pain during labour
causes generalised neuroendocrinal stress response including
increased oxygen consumption, hyperventilation, increased
cardiac output, impaired uterine contractility, metabolic
acidemia, and increased maternal-fetal mortality and mor-
bidity []. So, many labor pain management strategies
named painless childbirth methods have been developed
andwidelyusedinrecentyears[,]. Painless childbirth
methods include pharmacologic (such as regional anesthesia,
paracervical block, pudendal block, and systemic analgesia)
and nonpharmacologic methods (such as psychoprophylactic
method, hypnosis, and acupuncture).
Women may change their preferred delivery method due
to fear of labour pain and this is one of the most important
reasons of the increase in the rate of elective cesarean section
in recent years [,]. Studies have shown that women with
FOC require more use of pain relieving methods in labour
compared to women without FOC [].
We hypothesized that if women have knowledge about
painless childbirth, lower rate of FOC may be in these
patients compared to those without knowledge about painless
childbirth. us, aim of this study was to investigate the asso-
ciation between FOC and women’s knowledge about painless
childbirth in multiparous women with uncomplicated preg-
nancy.
Hindawi Publishing Corporation
Obstetrics and Gynecology International
Volume 2014, Article ID 274303, 7 pages
http://dx.doi.org/10.1155/2014/274303
Obstetrics and Gynecology International
2. Materials and Methods
is study was conducted at Nenehatun Hospital, Erzurum,
Turkey, a metropolitan teaching hospital performing approx-
imately deliveries/year. Nine hundred women in their
nal month of pregnancy reviewed at the hospital for ante-
natal care and decisions regarding delivery type between
January,andMay,wereselectedforthis
study. e protocol of the study was approved by the
Ethics Committee of our institute (the protocol number: )
and informed consent was obtained from all of the par-
ticipants. Only multiparous patients with positive experi-
ences were included in this study to minimize other factors
causing FOC such as nulliparity and previous experience
of a traumatic birth. Initially, obstetric examination was
performed to detect whether there was a maternal or fetal
problem. Women’s demographic-obstetric information was
recorded and patients were questioned for the determination
of whether they have inclusion criteria for this current study
using a semistructured interview technique (Appendix A).
Women with complicated pregnancies (e.g., preeclampsia,
fetal malformation, gestational diabetes mellitus, and pla-
centa previa), chronic illnesses (e.g., hypertension and dia-
betes mellitus), and multiple pregnancies were excluded
from the study. Patients were questioned about their birth
experience and the answers were analysed []. Women who
had had a negative birth experience (numeric rating scale
score (NRS) ≥) were excluded. Patients who delivered vagi-
nally with regional anaesthesia in previous pregnancy and
who had previous caesarean delivery were also excluded.
A questionnaire including the Wijma Delivery
Expectancy/Experience Questionnaire (W-DEQ) form A
was completed by the patients who have inclusion criteria
for this study. W-DEQ form version A, which is a prepartum
version of the scale, has a -item assessing FOC level
according to women’s cognitive appraisal and expectancies
about delivery (items like “How do you think you will
feel in general during the labour and delivery?” Extremely
weak-not at all weak, extreme panic-not at all panicked,
extremetrust-notrustatall).ItwasshownthatW-DEQform
version A had good internal consistency with a Cronbach’s 𝛼
coecient of . []. Each item has six scale points ranging
from to and total scores ranged from to . FOC is
dened as W-DEQ sum score ≥, and severe FOC is dened
as W-DEQ ≥ []. Turkish form of W-DEQ version A
was found to be reliable and valid (internal consistency
coecient for the WDEQ was .) in a sample of
Turkish preg n a nt women by Korukc u e t a l . [ ]andwasused
to detect FOC in this study. Participants’ responses to
questions were recorded.
Following completed W-DEQ form A, participants were
questioned about whether they had knowledge about painless
childbirth, the method of painless childbirth which they
hadmaximumknowledgeof,themostimportantsource
of this knowledge, and their preferred delivery method for
their current pregnancy (Appendix B). Participants were
also asked about whether they preferred painless childbirth
for current pregnancy, aer informing them about painless
childbirth methods (Appendix B). Individual informing was
performedbyanobstetriciantoevaluatewhetherpositive
information about painless childbirth methods has an eect
on caesarean delivery preference. Applicable pain relief meth-
ods and possible interventions and alternatives for pain relief
during labor were explained without technical details for
about one hour verbally. Questions of the patients with
suspicions about the painless childbirth methods (such as the
stroke risk due to the procedure) were answered.
A power analysis for this study was calculated based on
the work of Fenwick et al. []usingRussLenth’sPowerand
sample size calculation application []. It was calculated that
women were required to give % power (alpha %) to
detect a % dierence in FOC between groups and , if FOC
was % in group and % in group .
SPSS soware . (SPSS Inc., Chicago, IL, USA) was used
for the statistical analysis. e Kolmogorov-Smirnov test was
used to determine whether data had normal distribution.
e unpaired 𝑡test was used for analysis of participants
for dierences in demographic and obstetric characteristics.
Participants were divided two groups according to their
knowledge about painless childbirth: group 1:participants
with knowledge about painless childbirth and group 2:partic-
ipants who do not have knowledge about painless childbirth.
Mean W-DEQ scores of the two groups were compared using
the unpaired 𝑡test. e Pearson Chi-square test was used
forcomparisonofwomenwithFOCaccordingtowhether
they desired painless childbirth. e Chi-square test was used
to compare the preferred delivery methods of patients with
or without FOC in two groups. e data were calculated
as mean ±standard deviation and odds ratios (OR) with
% condence interval (CI). 𝑃 < 0.05 was considered as
signicant.
3. Results
Flow of participants into the study is shown in Figure .Of
eligible women, agreed to participate and had
exclusion criteria, leaving a nal study sample of included
women.
e women’s clinic characteristics and mean W-DEQ
scores are presented in Table .Fivehundredandtwenty-
four women (.%) were knowledgeable (group ), while
women (.%) had little knowledge about painless childbirth
(group ). Mean W-DEQ scores of participants in both
groups were . ±. (range, –). Mean W-DEQ scores
in group were found to be lower (. ±.) than in
group (. ±.) (𝑃 = 0.001). e percentage of patients
diagnosed with FOC in group (𝑛=76, .%) was higher
than in group (𝑛=69, .%) (𝑃 = 0.005,OR.,%CI
.–., Tabl e ). ere was no severe FOC (W-DEQ ≥) in
both of groups.
Regarding the painless childbirth method about which
participants in group had most knowledge, (.%)
patients knew that painless childbirth was provided by
inserting a needle in the lower back, and (.%) patients
knew that it was provided by intramuscular or intravenous
drug administration during labour pain (Tab l e ). Most of
the patients (, .%) said that they have received most
information from their friends (Tab l e ). ere were a total
Obstetrics and Gynecology International
Assessed for eligibility
(n = 2000)
Agreed to participate
(n = 1500)
Not meeting inclusion criteria (n=600)
- History of caesarean section (n=375)
- Negative birth experience (n = 180)
∙Abortion (n = 130)
∙Excessive blood loss (n=10)
∙Vacuum extraction (n=8)
∙Deep perineal laceration (n=17)
∙History of stillbirth (n=5)
∙A history of preterm birth (n=10)
- Complicated pregnancies (n=30)
∙Placenta previa (n=6)
∙Fetal malformation (n=4)
∙Gestational diabetes (n=7)
∙Hypertension (n=6)
∙Multiple pregnancies (n=7)
- Using regional anaesthesia in previous
pregnancies (n=5)
Analysed (n=900)
- A history of severe FOC (n=10)
F : Flow of participants into the study.
of patients with FOC in the two groups. e percentage
of patients with FOC was similar amongst university grad-
uates (/, .%) and those without a university degree
(/, .%) (𝑃 > 0.05).
e relationship between FOC and maternal preference
for delivery method is shown in Table .eoddsratioof
knowledge about painless childbirth was . (% CI .–
.) for preferring delivery methods. e analysis of our
data shows that request for caesarean section in .% of
womenresultedfromfearoflabourpain(Ta b l e ). ere
were a total of women with FOC, (.%) of them
desired elective caesarean section. FOC was associated with
preference for caesarean section (OR ., % CI .–.).
Aer they were informed positively about the methods of
painless childbirth, pregnant women changed their mind
and chose vaginal delivery with painless childbirth methods.
us, the proportion of women requesting caesarean section
droppedfrom.%to.%inwomenwithFOCandFOC
was associated with preferring painless childbirth (OR .,
% CI .–.). Two hundred and twenty-eight of all
patients (%) refused the methods of painless childbirth for
their current pregnancy due to various reasons (Figure ).
4. Discussion
In this study, we researched the relationship between FOC
and knowledge about painless childbirth in multiparous
women with a positive birth experience. Nine hundred
women answered the questionnaire, of them were knowl-
edgeable and of them were unknowledgeable about
painless childbirth. Mean W-DEQ scores and the percentage
of patients with FOC were signicantly higher in women with
little knowledge about painless childbirth than in women
who have knowledge about it. ere were a total of
patients with FOC in the study group (.%). Severe FOC
was not reported in our study. Whether or not they experi-
enced FOC, most of the patients who were knowledgeable
aboutpainlesschildbirthchosevaginalbirth.Aerpositively
informing them about the painless childbirth, almost all of
the women with FOC desired painless childbirth.
Although numerous studies have been conducted for
decades about FOC [–], the exact causes and treatment of
FOC have not been found as yet. Størksen et al. []found
strong association between previous subjectively negative
birth experience and FOC in the subsequent pregnancy.
Nilsson et al. []alsoshowedanassociationbetweenFOC
and negative birth experiences. Additionally, it has been
indicated that nulliparous women had higher mean W-DEQ
scores than parous women []. To minimize the factors that
caused FOC, multiparous patients with no negative birth
experiences only enrolled in this current study researching
the relationship between FOC and knowledge about painless
childbirth.
TurkishformofW-DEQversionAwasusedinthis
current study to measure the degree of fear of childbirth in
participants. Previously, it was showed that this form had
satisfactory internal consistency and Cronbach’s alpha (.)
for the Turkish version of the W-DEQ. ese results were
similar to the results of the developers of the scale in addition
to results of the British version [,]. Mean W-DEQ scores
of participants in this current study were . ±. (range,
–). Similar W-DEQ scores were reported by Fenwick et al.
[]andRouheetal.[](.±. (range –) and
. ±. (range –), resp.). But the score range in their
study was dierent from the score range in this current study.
As the reason for this dierence, it may be said that the
women with negative birth experiences were excluded from
this current study population. So, there were no women with
W-DEQ sc ores ≥ in this current study.
Pregnancy and the delivery processes may be intolerable
for women with FOC. In a study [] examining the intensity
and type of childbirth fears, fear for the child’s health and
fear of pain were found to be the most frequent fears. e
researchers reported that most women with FOC chose to
have a caesarean section rather than vaginal delivery because
of fear of labour pain []. Similar to these results, caesarean
section was preferred in a higher rate than vaginal delivery
Obstetrics and Gynecology International
T : Women’s demographic and obstetric characteristics and mean W-DEQ scores.
Characteristic Group
(𝑛 = 524, .%)
Group
(𝑛 = 376,.%) 𝑃value
Age (years) . ±. . ±. >.
Parity . ±. . ±. >.
Gestational week . ±. . ±. >.
BMI (kg/m). ±. . ±. >.
Mean W-DEQ scores . ±. . ±. =.
W-DEQ scores (min, max) , ,
Patients with FOC (𝑛,%) , .% , .% =.
University graduates (𝑛,%) ,.% ,.% >.
Group : participants with knowledge about painless childbirth, group : participants who do not have knowledge about painless childbirth.
T : Methods of painless childbirth about which participants
had knowledge.
Method of painless childbirth Number of participants
that have knowledge
Provided by inserting a needle in the
lower back , .%
Provided by intramuscular or
intravenous drug administration , .%
Other (e.g., acupuncture, deep
breathing exercise) , .%
Source of knowledge about painless
childbirth 𝑛,%
My friends: (.%),
Television:(.%),
Internet: (.%),
Doctor: (.%),
Nurse: (.%).
by women with FOC compared to those without FOC in our
study.
In our hospital, painless childbirth methods have been
applied to the patients who wish painless childbirth and also
elective caesarean section for maternal request has not been
performed. Unfortunately, a large proportion of women do
not have knowledge about the methods of painless child-
birth. e incidence of awareness and acceptance of labour
analgesiahavebeenreportedas.and%intheIndian
population [], and .% in the Nigerian population [],
and and % in the Australian population []. However,
thepercentageofwomenwhohaveknowledgeaboutpainless
childbirth was found to be as .% in our study. But some of
these patients had suspicions and fears about the pain relief
methods. Aer positive informing about painless childbirth
methods of all patients, acceptance of painless childbirth was
.%inallwomen,%inwomenwithFOC,and.%
in women without FOC in this current study. e most
important reason for refusal of painless childbirth among
patients was the request to have a natural birth. Also the
percentage of women dened as FOC was higher in women
who were unknowledgeable about painless childbirth than in
women who were knowledgeable about it in our study.
In our study, with respect to the source of their knowledge
about painless childbirth, more women received knowledge
from their friends, similar to Naithani et al.’s []study.
However, the anaesthetist or obstetrician was reported as a
source of information in the Australian population []. e
reason for this dierence may be that most of our study
populationconsistedofpeoplewhohadnotgraduatedfrom
university.
One target for reducing rates of elective caesarean section
is to reduce rates of caesarean section for maternal request,
which have been increasing [,]. A relationship has
previously been found between FOC and maternal request for
elective caesarean section []. Sydsj¨
oetal.[]showedthat
secondary FOC prolongs the time to subsequent delivery and
theactivephaseoflabouritselfandincreasestheriskforcae-
sarean section. Furthermore, we reported that women (FOC
or not) with knowledge about painless childbirth requested a
lower choosing rate of caesarean section compared to women
without knowledge about it. We also reported a lower rate of
caesarean section request aer positively informing women
with FOC about painless childbirth.
e limitation of this study is that what the mode of birth
ended up being is not actually known.
5. Conclusions
Fear of labour pain was found to be the major cause of
Turkish women requesting elective caesarean section.Turk-
ish women’s knowledge about painless childbirth methods is
insucient. Better informing pregnant women about painless
childbirth methods may reduce the number of women with
FOC, the severity of fear in women, and the rate of choosing
elective caesarean section due to fear of labour pain. Also,
itmayincreasetheuseofpainlesschildbirthmethodsby
women. Future studies including postpartum data need to
detect the association between fear of childbirth and women’s
knowledge about painless childbirth.
Appendix
A. The First Questionnaire Form
Used for Multiparous Patients in
this Study Population
(A)
(i) e rst letters of rst and last name:
Obstetrics and Gynecology International
T : Delivery preference of participants and reasons for requesting elective caesarean section.
Patients preferring caesarean section for
their current pregnancy
𝑛,%
Patients preferring vaginal delivery for
their current pregnancy
𝑛,%
e patients with FOC in group (𝑛=69)
∗, . ∗, .
e patients with FOC in group (𝑛=76) , , .
e patients without FOC in group (𝑛 = 455)
∗∗,
∗∗,.
e patients without FOC in group (𝑛 = 300) , . , .
Causes for preferring caesarean section
(𝑛 = 233)
(i) Fear of pain caused by uterine contractions (𝑛= , .%)
(ii) Control request delivery time (𝑛=50, .%)
(iii) Fear of perineal tear (𝑛=19, .%)
(iv) Request of tubal ligation (𝑛=9, .%)
Group : participants with knowledge about painless childbirth, group : participants who do not have knowledge about painless childbirth. ∗𝑃 < 0.0001,
compared to the patients with FOC in group ; ∗∗𝑃 < 0.001, compared to the patients without FOC in group .
Participants who refused painless Participants who desired
Participants with FOC
who refused painless
childbirth
Participants without
FOC who refused
painless childbirth
Participants with FOC
who desired painless
childbirth
Participants without
painless childbirth
Participants in this study (n=900)
(n = 145 with FOC; n = 755 without FOC)
FOC who desired
Reasons for rejecting painless childbirth (n = 228)
∙Desire for a natural method of childbirth
∙e idea that the method will not reduce the
∙Concern that the method can damage the baby
Reasons for choosing painless childbirth (n = 672)
childbirth (n = 228, 25.3%)painless childbirth (n = 672, 74.6%)
(n = 25∗,17.2%) (n = 203, 26.8%) (n = 120∗, 82.7% ) (n = 552, 73.1% )
(n = 150, 65.7% )
labour pain (n = 50, 21.9% )
and mother (n = 28, 12.2%)
∙Intolerance to labour pain (n = 550, 81.8%)
∙Recommended by doctors (n = 122, 18.1%)
F : Distribution of participants according to whether they preferred painless childbirth aer being informed about painless childbirth.
FOC: fear of childbirth, ∗𝑃< 0.001 compared to participants without FOC.
(ii) Phone number:
(iii) Age:
(iv) Length:
(v) Weight:
(vi) Parity:
(vii) Gestational week:
(viii) e level of education:
(a) University graduate
(b) Non-university graduate
(B)
(i) Previous birth experiences.
(a) A history of cesarean section:
(b) A history of being diagnosed with severe
fear of childbirth in previous pregnancies:
(c) A history of negative birth experience:
() abortion
() excessive blood loss
() vacuum extraction
() deep perineal laceration
() stillbirth
() preterm birth
() other:
(ii) Complicated situations in the current preg-
nancy:
(a) placenta previa
Obstetrics and Gynecology International
(b) fetal malformation
(c) gestational diabetes
(d) hypertension
(e) multiple pregnancy
(f) other:
(iii) A history of using regional anesthetic methods
in previous births:
(iv) Numeric rating scale (NSR) score: Please give a
number for the overall experience of your birth
from (very good) to (extremely bad):
∗∗If you have any of the conditions in B section or your
NSR score is nine or more, please return the questionnaire
form to interviewer. If you do not have any of the conditions
in B section or your NSR score is eight or less, you may
continue to respond the questions in the Wijma Delivery
Expectancy/Experience Questionnaire form A.
B. The Questionnaire Form Used
after Completed Wijma Delivery
Expectancy/Experience Questionnaire Form
A for Multiparous Patients in
this Study Population
(C)
(i) Haveyouknowledgeaboutpainlesschildbirth?
(a) Yes
(b) No
(ii) Which is the method of painless childbirth that
you had maximum knowledge about it?
(a) It is provided by inserting a needle in the
lower back
(b) It is provided by intramuscular or intra-
venous drug administration
(c) Other (Acupuncture, deep breathing exer-
cise, e.g.)
(iii) What is the most important source of this
knowledge for you?
(a) My friends
(b) Television
(c) Internet
(d) Doctor
(e) Nurse
(f) Other
(iv) What is your preferred birth type for the current
pregnancy?
(a) Normal vaginal delivery
(b) Elective caesarean section
(v) Which is the most important reason in choosing
caesarean section for you?
(a) Fear of pain caused by uterine contractions
(b) Control request delivery time
(c) Fear of perineal tear
(d) Request of tubal ligation
(e) Other
Pleasecontactyourobstetrician,beforeansweringthefol-
lowing questions. You will be informed about applicable pain
relief methods and possible interventions and alternatives for
pain relief during labor by your obstetrician for about one
hour.
∗∗Please answer the following questions aer informing
by your obstetrician.
(i) Would you prefer a normal birth with a painless
deliverymethodforyourcurrentpregnancy?
(a) Yes
(b) No
(ii) Please, mark the most important reason for you in
choosing the methods of painless childbirth
(a) Intolerance to labour pain
(b) Recommended by doctors
(c) Other
(iii) Please, mark the most important reason in not choos-
ing the methods of painless childbirth for you.
(a) Desire for a natural method of childbirth
(b) e idea that the method will not reduce the
labour pain
(c) Concern that the method can damage the baby
and mother
(d) Other
Conflict of Interests
e authors declare that there is no conict of interests
regarding the publication of this paper.
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