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ISSN: 0167-482X (print), 1743-8942 (electronic)
J Psychosom Obstet Gynaecol, Early Online: 1–9
!2014 Informa UK Ltd. DOI: 10.3109/0167482X.2014.980722
ORIGINAL ARTICLE
Group psychoeducation with relaxation for severe fear of childbirth
improves maternal adjustment and childbirth experience – a
randomised controlled trial
Hanna Rouhe
1
, Katariina Salmela-Aro
2
, Riikka Toivanen
1
, Maiju Tokola
1
, Erja Halmesma
¨ki
1
, Elsa-Lena Ryding
3
, and
Terhi Saisto
1
1
Department of Obstetrics and Gynaecology, Helsinki University Central Hospital, Helsinki, Finland,
2
University of Jyva
¨skyla
¨, Department of
Psychology, Jyva
¨skyla
¨, Finland and Cicero learning, Institute of Behavioural Sciences, University of Helsinki, Helsinki, Finland, and
3
Department of
Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
Abstract
Background: Previous studies on the treatment of women with fear of childbirth have focused
on the delivery mode. Women with fear of childbirth often suffer from anxiety and/or
depression, and treatment therefore also needs to target postnatal psychological well-being
and the early mother–infant relationship.
Methods: Three hundred and seventy-one nulliparous women out of 4575 scored 100 in
prospective screening (Wijma Delivery Expectancy Questionnaire, W-DEQ-A), indicating severe
fear of childbirth. These women were randomised to psychoeducative group intervention with
relaxation (n¼131; six sessions during pregnancy, one postnatal) or to conventional care
(n¼240) by community nurses (referral if necessary). Psycho-emotional and psychosocial
evaluations [Edinburgh Postnatal Depression Scale (EPDS), social support, Maternal Adjustment
and Attitudes (MAMA), Traumatic Events Scale (TES) and the Wijma Delivery Experience
Questionnaire (W-DEQ-B)] were completed twice during pregnancy and/or 3 months
postpartum.
Results: Postnatal maternal adjustment (MAMA mean score 38.1 ± 4.3 versus 35.7 ± 5.0,
p¼0.001) and childbirth experience (mean W-DEQ-B sum score 63.0 ± 29 versus 73.7 ± 32,
p¼0.008) were better in the intervention group compared with controls. In hierarchical
regression, social support, participating in intervention, and less fearful childbirth experience
predicted better maternal adjustment. The level of postnatal depressive symptoms was
significantly lower in the intervention group (mean sum score 6.4 ± 5.4 versus 8.0 ± 5.9 p¼0.04).
There were no differences in the frequency of post-traumatic stress symptoms between the
groups.
Conclusions: In nulliparous women with severe fear of childbirth, participation in a targeted
psychoeducative group resulted in better maternal adjustment, a less fearful childbirth
experience and fewer postnatal depressive symptoms, compared with conventional care.
Keywords
Childbirth experience, fear of childbirth,
maternal adjustment, postnatal
depression, post traumatic stress
syndrome
History
Received 19 March 2013
Revised 9 October 2014
Accepted 22 October 2014
Introduction
As many as 6–10% of pregnant women suffer from severe fear
of childbirth [1–5]. Severe fear of childbirth interferes with
normal life and prevents preparation for the upcoming
childbirth. Fear of childbirth can also complicate labour and
lead to difficulties in mother–infant relationships and to
postnatal depression [6–8]. A common manifestation of
severe fear of childbirth is the request or demand for
caesarean section (CS) [9]. Further, women with prior fear
of childbirth are at a greater risk of post-traumatic stress
symptoms or disorder after childbirth [7]. Clinical practice
regarding how to treat women with fear of childbirth has
mainly been focused on the mode of delivery as an outcome
variable. No randomised intervention study has been carried
out to investigate maternal well-being postpartum.
Over the last few decades, trained midwives, obstetricians
and psychologists have offered various kinds of therapy and
support to relieve fear of childbirth and to avoid unnecessary
CS. As a result, 50–85% of patients with fear of childbirth can
prepare themselves for vaginal delivery after receiving help,
and CS can be avoided [10–15].
Address for correspondence: Hanna Rouhe, Department of Obstetrics
and Gynaecology, Helsinki University Central Hospital, P.O. Box 800,
00029 HUS, Finland. Email: hanna.rouhe@helsinki.fi.
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Women with anxiety-prone personalities are more at risk
for experiencing fear of childbirth [16,17]. Further, greater
fear of childbirth has previously been shown to be associated
with mental health problems such as depression, anxiety and
panic disorder [18,19]. Women with fear of childbirth are
known to have a higher risk of postnatal depression, even
without a history of depression [20]. It is also known that
mental health problems before and during pregnancy, as
well as prenatal stress, are often linked to poorer maternal
adjustment [21]. As fear of childbirth causes significant stress
during pregnancy [13], it may therefore interfere with
maternal adjustment. A systematic review revealed that in
women with postnatal depression, forms of intervention
supporting mother–infant relationships can improve maternal
adjustment and have a positive impact on infant development
[22]. However, there have been no randomised studies about
interventions improving maternal adjustment in women with
fear of childbirth.
Previous studies about childbirth experience have shown
that a positive evaluation of experience is more common after
a spontaneous vaginal delivery [23] and the highest risk for
traumatizing experience is after an emergency CS [24].
However, it is also known that the majority of traumatised
women have also had a normal delivery [24]. Fear of
childbirth is known to be a risk factor for negative childbirth
experience and post-traumatic stress disorder [7,25,26], but
how to prevent these negative effects in fearful women is not
known. There have been no randomised studies of women
which have explicitly considered the childbirth experience of
women who suffer from severe fear of childbirth.
The aim of this randomised study was to assess the effects
of group psychoeducation versus conventional care during
pregnancy on postnatal maternal adjustment, childbirth
experience, depressive symptoms and post-traumatic stress
symptoms. We were also interested in exploring any effects of
psychosocial background, social support, mental health,
group psychoeducation and delivery mode on maternal
adjustment and childbirth experience.
Materials and methods
Between October 2007 and August 2009, at the time of
routine ultrasonography screening at the gestational age of
11–13 weeks, fear of childbirth was screened via the
Wijma Delivery Expectancy Questionnaire (W-DEQ-A, see
below) [27]. All participants gave their informed consent.
Altogether, 4575 questionnaires from nulliparous women
were returned and those who scored 100 were included in
our study. The final study population consisted of 371
women (8.1% of the 4575) who were randomised (in a
proportion of 1:2 in balanced blocks of 18 via sealed opaque
envelopes by senior researcher T.S.) to the intervention
group (n¼131) and to the control group (n¼240) [15].
There were no differences between the groups in level of
fear of childbirth, age, socioeconomic or marital status or in
the numbers of previous miscarriages or terminations of
pregnancy [15]. Women in the intervention group were
contacted by mail and offered group psychoeducation in
connection with fear of childbirth. Those randomised to the
control group received a letter in which they were advised, if
necessary, to discuss their fear of childbirth in their
maternity unit in primary health care.
After screening and randomisation (Time 0), the women
and their partners in both groups separately received three
questionnaires: in mid-pregnancy (at 20 ± 2 gestational
weeks, Time 1), at the end of the third trimester (at 36 ± 2
gestational weeks, Time 2) and 3 months after delivery (at 3
months ± 2 weeks postpartum, Time 3). These questionnaires
included psychological, social and maternal adjustment-,
pregnancy- and delivery-related questions (Table 1).
Completing the questionnaires did not influence care. If the
questionnaires were not returned, the women were reminded
twice by email or a new questionnaire was sent by mail. The
main outcome measures were maternal adjustment [28],
fearful childbirth experience [27], postnatal depressive symp-
toms [29] and traumatic stress symptoms or post-traumatic
stress disorder (PTSD) [30].
This study was approved by the Ethics Committee for
Gynaecology and Obstetrics, Otology, Ophthalmology,
Neurology and Neurosurgery of Helsinki University Central
Hospital (376/E9/05 from 27 October 2005) and informed
consent was collected from everyone who filled in any of the
questionnaires.
Intervention
The intervention method used to treat women with severe fear
of childbirth was group psychoeducation with relaxation
exercises. Six group sessions were held during pregnancy
(starting at mean the 28th week of pregnancy) and one 6–8
weeks after delivery (Table 2). Sessions were led by a
psychologist with specialised skills in group therapy and
pregnancy issues. Each group consisted of a maximum of six
nulliparous women. The sessions (2 h) had a fixed structure: a
focused topic and a 30-min relaxation with mindfulness
guided exercise, using a compact audio disk developed for
this purpose. Every session began with the therapist setting
the agenda for the coming session and the sharing of feelings
and thoughts that came up after the previous session. Then
Table 1. Study protocol: questionnaires used at each time point, number
of questions concerned and references.
Variable (number of questions) References
Time 0: Background information (16)
Early pregnancy W-DEQ-A (33) [27]
(screening)
Time 1: Background information (16)
Mid-pregnancy Depression (EPDS) (10) [29]
Social support (7) [37]
Time 2: Background information (6)
1 month before
delivery
Depression (EPDS) (10) [29]
Time 3: Pregnancy and delivery
information (27)
3 months after
delivery
Depression (EPDS) (10) [29]
Social support (7) [37]
W-DEQ-B (33) [27]
Traumatic Event Scale
(TES) (38)
[30]
MAMA (12) [28]
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there was a guided discussion on the topic of the session and
the session ended with the relaxation exercise. The guided
relaxation exercise takes the participants through all stages of
delivery in a relaxed state of mind with positive, calming and
supportive suggestions or alternatively, a breathing exercise.
The development of the group intervention was based on
experience with therapeutic group work, attachment the-
ory, social cognitive theories and individual coping strategies
[31–33]. Personal and external conditions play a major role in
generating women’s fears of childbirth and reflect women’s
anxieties about maintaining a sense of personal control and
self-efficacy [24]. The aim of the intervention was to enhance
preparedness for childbirth among nulliparous women with
severe fear of childbirth. The focus of the intervention was to
share the difficult emotions and fears concerning the delivery
and increase the feelings of safety and trust within the
participants. Another aim was to strengthen the participants’
confidence in themselves regarding childbirth and mother-
hood, and also to increase their knowledge of the stages of
delivery. In the study protocol, the women in the intervention
group had no planned visits with the obstetrician. A more
detailed description of our psychotherapeutic intervention
method has been published previously [34]. Intervention is
semi-structured so that the protocol is possible to repeat after
proper training, while retaining emotional space and flexibil-
ity to deal with each group’s specific concerns. To ensure
consistency of the intervention between groups, the original
therapists (RT and MT) trained two new psychologists in
delivering this protocol.
The participation rate in the intervention was 69% (n¼90)
among those invited. Of the 240 women in the control group,
a total of 76 were sent from primary care to outpatient
maternity clinics for a special consultation due to fear of
childbirth, and they met an obstetrician 1–5 times (mean 1.7,
mode 1) and/or a midwife 1–4 (mean 1.3, mode 1) times.
Moreover, 30 control women attended an advanced prepar-
ation class led by a specialised midwife 2–6 times (mean 2.5,
mode 2) during pregnancy [15]. Obstetric results have already
been published [15]. In short, women randomised to the
intervention group more often had spontaneous vaginal
deliveries than the controls (63.4% versus 47.5%, p¼0.005)
as well as fewer CSs (22.9% versus 32.5%, p¼0.05).
Questionnaires
The maternal adjustment and maternal attitudes (MAMA)
questionnaire is a 60-item self-assessment questionnaire [28].
We used the postnatal version of the scale regarding maternal
adjustment and attitudes 3 months after delivery. It consists of
12 items and the women were asked to answer each item on a
scale of 1 (not at all/never) to 4 (very much/very often) during
the last month. Higher scores reflect higher levels of
adjustment and more positive attitudes. Cronbach’s alpha
coefficient was 0.80.
The Wijma Delivery Expectancy/Experience Question-
naire (W-DEQ) [27] is a self-assessment questionnaire
including 33 statements about childbirth, on a scale ranging
from ‘‘not at all’’ (zero) to ‘‘extremely’’ (five), with a
maximum score of 165 and minimum of zero. The higher the
score, the more severe the fear of childbirth. W-DEQ form A
measures the degree of fear of childbirth for the future. A W-
DEQ-A sum score of 100 has been used in previous studies
[3,4,35] to represent very severe fear of childbirth. W-DEQ-B
measures the childbirth experience, including statements
about the experience of fear in relation to the previous
delivery, sometimes described as postnatal fear of childbirth.
The higher the score, the more fearful or negative the
childbirth experience. After approval from the copyright
holder K. Wijma (personal communication), W-DEQ-A and
-B were translated into Finnish and used among the Finnish
population [3]. The Cronbach’s alpha reliability coefficient
was 0.94 for W-DEQ-A and 0.95 for W-DEQ-B.
The Edinburgh Postnatal Depression Scale (EPDS) was
used to measure depressive symptoms in mid-pregnancy
(Time 1), late pregnancy (Time 2) and 3 months after
childbirth (Time 3). The EPDS was originally developed to
assess postnatal depressive symptoms [29], but has been
validated for prenatal use as well [36]. Each item is rated on a
scale of 0–3 and all items are added to form an overall score.
Cronbach’s alpha coefficients were: Time 1, 0.87, Time 2,
0.85 and Time 3, 0.90.
The Traumatic Event Scale (TES) was used to measure
post-traumatic stress symptoms related to childbirth, 3
months after delivery [30]. The scale was developed in line
with DSM-IV (Diagnostic and Statistical Manual of Mental
Disorders, fourth edition) criteria for PTSD and comprises the
stressor criterion (criterion A) and all symptom criteria for
PTSD including criteria E (time criterion) and F (influence on
life). The scale includes four statements about criterion A
(stressor) and 17 statements concerning PTSD criteria B, C
and D (i.e. intrusive thoughts, avoidance/numbing and
arousal). The subjects were asked to report the frequency of
each symptom described on a scale of 1 (never/not at all) to 4
(often). Higher TES sum scores indicate that those women
more frequently have PTSD symptoms in connection with the
recent delivery. The Cronbach’s alpha coefficient was 0.88.
A TES-F criterion is the reported influence of the symptoms
on the parturient’s life, on a scale of 0–10. For a PTSD profile
(very probable diagnosis, but interview always needed)
according to DSM-IV, criteria were fulfilled if items A, B,
Table 2. Manner of intervention: group psychoeducation with relaxation
exercises. In all sessions, a guided relaxation period of 30 minutes was
included.
Group
session Focused topic
1. Information about fear and anxiety, group psychoeducation and
effects of relaxation.
2. Information about fear of childbirth, normalisation of individ-
ual reactions and information about stages of labour.
3. Hospital routines, birth process and pain relief (midwife
present).
4. Becoming a family, changes in relationship, parenthood and
enhancing mutual understanding when becoming parents
(partners present).
5. Becoming a mother, recognizing the signs of postnatal
depression and bonding with the infant.
6. Completing preparation for delivery, and birth plan.
7. Meeting 2–3 months after delivery with new-borns, discussion
of delivery experiences, detection of trauma and depression
symptoms and discussion of mother–infant relationship.
DOI: 10.3109/0167482X.2014.980722 Effects of group psychoeducation versus conventional care during pregnancy 3
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C, D and E were fulfilled and the degree to which they
influenced life was 6–10 as regards at least one of the
symptoms.
The need for and availability of social support were
assessed by asking seven questions concerning the kind of
mental support and help the women had received from their
friends and relatives [37]. The women were asked to answer
each question on a scale of 1 (never) to 5 (all the time).
Higher scores indicate more social support. Cronbach’s alpha
coefficient at Time 1 was 0.92 and at Time 3, 0.94.
Statistics
Statistical analyses were carried out using PASW 18.0
(Predictive Analytics Software, Chicago, IL). Student’s t-test
was used for parametric variables with normal distribution
(W-DEQ-B) and the (non-parametric) Mann–Whitney U-test
for parametric variables with much skewed distribution
(EPDS, TES). To be able to evaluate the effect of group
psychoeducation on the change in depressive symptoms, we
used repeated two-way (group psychoeducation time)
ANOVA. A value of p0.05 was considered significant.
Intention-to-treat analyses were completed unless otherwise
indicated.
The power calculations were done to detect a difference of
30% between the group intervention and the controls in the
frequency of spontaneous vaginal delivery [15] and showed
that 135 women were needed in both groups, 80% power at
p¼0.05. After the power analysis and a consultation with the
statistician, we decided to recruit two control women for each
case as we wanted to optimise the number of returned
questionnaires.
Two separate hierarchical regression analyses were carried
out to investigate the antecedents of (1) a fearful childbirth
experience and (2) maternal adjustment. Variables were
entered in the following order:
(1) socioeconomic factors (age, university education, living
with a partner),
(2) social support and depressive symptoms in mid-
pregnancy,
(3) participation in group psychoeducation and relaxation
exercises (yes or no),
(4) depressive symptoms in late pregnancy,
(5) delivery mode (spontaneous vaginal delivery or operative
delivery [CS, vacuum extraction]),
(6) postnatal depressive symptoms and traumatic stress
symptoms 3 months after delivery.
In order to investigate the effect of a fearful childbirth
experience on maternal adjustment, childbirth experience was
added to the sixth level when analysing maternal adjustment.
Interpretation of the results was based on an increase in
Rsquared (R
2
) after each stage of prediction, and on an
adjusted beta coefficient used to estimate the effect of each
antecedent on selected dependent variables.
Attrition analysis
In order to exclude any bias related to the returned
questionnaires, we carried out an attrition analysis concerning
those who answered the questionnaires fully and those who
did not reply. There was no significant difference between
these two groups in W-DEQ-A sum scores at the time of
screening (not replied, mean 112.9 ± 12.6 [SD] versus
answered, 112.7 ± 11.3 [SD], NS).
Results
The results are presented in the following order: maternal
adjustment, childbirth experience, depressive symptoms and
traumatic symptoms. There was no significant difference
between the intervention group and the control group in the
numbers of returned questionnaires at mid-pregnancy or
3 months after delivery, only at late pregnancy there was a
significant difference between the groups (63% in interven-
tion group versus 50% in control group; Table 3).
Maternal adjustment
The MAMA sum score (n¼194) distribution was negatively
skewed (mean 36.6 ± 4.9, median 37, skewness 0.57,
kurtosis 0.13). The distribution of these data enabled the
use of both the t-test and Mann-Whitney U-test and we
decided to use t-test comparing the means between the
groups. Women randomised to the intervention group showed
better maternal adjustment 3 months after childbirth com-
pared with women in the control group (mean sum score
38.1 ± 4.3 versus 35.7 ± 5.0, F¼2.4, df ¼192, p¼0.001
Cohen d¼0.51, medium effect size).
The results of the hierarchical regression analysis showed
that socioeconomic factors, depressive symptoms in early
pregnancy and delivery mode had no significant effect on
maternal adjustment (Table 4). Social support both in early
pregnancy and by way of participating in group psychoeduca-
tion predicted better maternal adjustment. Depressive symp-
toms measured after childbirth had a strong negative
correlation to maternal adjustment. In addition, a less fearful
childbirth experience (low W-DEQ-B score) also predicted
better maternal adjustment (Table 4).
Childbirth experience
The W-DEQ-B sum score (n¼201) was normally distributed
(mean 69.6 ± 31, skewness 0.30, kurtosis 0.37). There was a
Table 3. Returned questionnaires and gestational age at returning point.
Intervention group (n¼131) Control group (n¼240)
Questionnaire n(%) Weeks mean ± SD n(%) Weeks mean ± SD p*
Time 1, gestational age 107 (82%) 21.5 ± 3.7 177 (74%) 21.0± 3.7 NS
Time 2, gestational age 82 (63%) 36.5 ± 1.7 121 (50%) 35.6 ± 2.0 0.001
Time 3, weeks after delivery 77 (59%) 18 ± 5 123 (51%) 19 ± 7 NS
*Difference between groups in the numbers of returned questionnaires.
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significant difference between the groups in mean W-DEQ-B
sum scores (intervention group 63.0 ± 32 versus control group
73.7 ± 29, F¼1.1, df ¼199, p¼0.016 Cohen d¼0.35, small
effect size), indicating a more fearful childbirth experience in
the control group. The W-DEQ-B sum scores according to
delivery mode and study group are presented in Table 6.
Childbirth experience was less fearful in the intervention
group compared to the control group across all modes of
delivery, although none of the differences reached signifi-
cance, potentially because of small sample sizes.
The results of the hierarchical regression analysis of a
fearful childbirth experience showed that socioeconomic
factors and depressive symptoms in mid-pregnancy had no
significant effect on the childbirth experience (Table 4).
Depressive symptoms in late pregnancy were a predictor of
fearful delivery experience. In this hierarchical regression, the
group psychoeducation just failed to reach significance in
contributing towards a more positive childbirth experience
(p¼0.06), mainly because of highly powerful variables in
previous levels of this regression model. A high level of social
support in middle pregnancy and spontaneous vaginal deliv-
ery was associated with a positive effect on the childbirth
experience, making it less fearful. Post-traumatic symptoms
after delivery were very strongly associated with fearful
delivery experience (Table 4).
Postnatal depressive symptoms
Distribution of the postnatal EPDS sum scores (n¼201) was
positively skewed (mean 7.4 ± 5.8, range 0–26, median 7.0,
skewness 1.03, kurtosis 0.97). As the EPDS sum score
distribution was skewed, we used Mann–Whitney U-test
Table 4. Hierarchical regression analyses concerning fearful childbirth experience and maternal adjustment.
Childbirth experience (W-DEQ-B) (n¼201) Maternal adjustment (n¼194)
Predictor
Increase in the %
of explanation (R
2
) B (CI 95%)
Increase in the %
of explanation (R
2
) B (CI 95%)
1. Socioeconomic background 0.022 0.012
Age 0.12 (0.31, 2.04) 0.04 (0.24, 0.15)
University education 0.12 (18.18, 2.95) 0.08 (2.55, 0.97)
Living with partner 0.04 (23.12, 35.77) 0.08 (7.63, 2.89)
2. Middle pregnancy 0.057* 0.098**
Social support 0.23** (2.46, 0.39) 0.26 (0.10, 0.43)**
Depressive symptoms 0.03 (0.85, 1.26) 0.12 (0.29, 0.05)
3. Group psychoeducative
treatment for fear of childbirth
0.023 0.16 (20.2, 0.23) 0.029* 0.17 (0.18, 3.48)*
4. Depressive symptoms
in late pregnancy
0.044y0.29y(0.53, 3.26) 0.018 0.19 (0.43, 0.03)
5. Delivery mode 0.055y0.003
Spontaneous vaginal delivery 0.25y(25.28, 5.78) 0.06 (1.05, 2.24)
6. Three months after delivery 0.403z0.329z
Fearful childbirth experience 0.27 (0.38, 0.01)*
Traumatic symptoms 0.80z(2.00, 2.83) 0.08 (0.15, 0.07)
Depressive symptoms 0.09 (1.39, 0.24) 0.54 (0.63, 0.32)z
*p50.05, yp50.01, zp50.001.
Standardised Beta (B) provides information about the association after the impact of other predictors included.
Table 5. Pearson correlations between variables in regression analysis.
Age
University
education
Living
together
Depressive
symptoms
in
middle
pregnancy
Social
support
in middle
pregnancy
Group
psycho
education
Depressive
symptoms
in late
pregnancy
Spontaneous
vaginal
delivery
Fearful
childbirth
experience
Traumatic
symptoms
Depressive
symptoms
after
childbirth
Maternal adjustment 0.05 0.08 0.05 0.15 0.27 0.22 0.20 0.09 0.49 0.51 0.60
Age 0.30 0.20 0.14 0.06 0.06 0.32 0.15 0.05 0.10 0.10
University education 0.19 0.30 0.07 0.08 0.30 0.02 0.09 0.09 0.03
Living together 0.05 0.12 0.04 0.05 0.03 0.10 0.05 0.02
Depressive symptoms
in middle pregnancy
0.33 0.14 0.61 0.14 0.10 0.37 0.52
Social support in middle
pregnancy
0.20 0.43 0.04 0.24 0.44 0.44
Group therapy 0.10 0.18 0.20 0.10 0.21
Depressive symptoms
in late pregnancy
0.11 0.23 0.42 0.48
Spontaneous vaginal
delivery
0.27 0.14 0.01
Fearful childbirth
experience
0.70 0.33
Traumatic symptoms 0.61
The bolded values indicate a significance of p50.05.
DOI: 10.3109/0167482X.2014.980722 Effects of group psychoeducation versus conventional care during pregnancy 5
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comparing the distributions between the groups. There were
significantly less severe postnatal depressive symptoms in the
intervention group compared to the control group (mean
EPDS sum score 6.4 ± 5.4 versus 8.0 ± 5.9; p¼0.04, Cohen
d¼0.28, small effect size).
Change in depressive symptoms
The results in linear change (during pregnancy and after
delivery) in depressive symptoms (EPDS) showed that linear
change (Time 1. mean EPDS score 8.3 ± 5.8 versus 8.9 ± 5.0,
Time 2. 7.5 ± 5.2 versus 8.1 ± 4.7, Time 3. 6.4 ± 5.4 versus
8.0 ± 5.9) was not significant (F[1, 157] ¼0.37, NS), whereas
the quadratic change was significant (F[1, 157] ¼3.99,
p50.05), indicating a decrease in depressive symptoms in
both groups after delivery, this being stronger in the
intervention group. The main effect as regards depressive
symptoms was significant (linear F[157] ¼5.73, p¼0.018),
indicating a decrease in depressive symptoms during preg-
nancy and after delivery among all women.
Traumatic stress symptoms
The distribution of TES data (n¼200) was positively skewed
(mean sum 27.0 ± 8.3, median 26, skewness 0.82, kurtosis
0.14). Between the groups, there was no significant difference
in post-traumatic symptoms or in probable PTSD (altogether
44 women 21.9% of women who replied) between the groups.
Symptoms of post-traumatic stress were associated with mode
of delivery, the most traumatizing being emergency CS
(Pearson’s correlation, k¼0.19, p¼0.009).
Discussion
This randomised study revealed that group psychoeducation
with relaxation exercises during pregnancy had a positive
impact not only on the mode of delivery [15], but also on
maternal adjustment, childbirth experience and depressive
symptoms in primiparous women with severe fear of
childbirth.
Mother–child attachment is already developing during
pregnancy [38,39]. However, this fragile and important
process is vulnerable to disturbances [40]. It is known from
previous studies that mental health problems, such as
depression and personality disorders, negatively affect mater-
nal adjustment [21,41,42]. Problematic parenting, in turn,
affects a child’s development and therefore increases the risk
of behavioural and emotional disturbances later in life [43–
45]. Our results show that the maternal adjustment of women
with fear of childbirth was supported by psychoeducative
group therapy. In comparison to a previous study of maternal
adjustment measured by MAMA, results of our control group
were not only as good as in an unselected population, but also
very comparable to the group with personality disorders and
other mental health problems [42]. In our study, women who
suffered from severe fear of childbirth and underwent group
psychoeducation showed better adjustment, which was in line
with that in an unselected population [42]. When motherhood
and parenting are discussed in the psychoeducation sessions,
the mother-to-be can create an image of her infant and this
way the mother–infant relationship begins to develop during
pregnancy [46]. Our results show that positive childbirth
experience also independently improved maternal adjustment.
The reason could be that if mothers’ self-confidence during
childbirth is promoted, it may also have positive effects on
later experiences of motherhood.
This is the first randomised study to measure fearful
childbirth experience with the W-DEQ-B after treatment of
severe fear of childbirth. Our results revealed that even though
the study population was extremely fearful during pregnancy
(490th percentile in W-DEQ-A scores), childbirth experience
was normally distributed and the W-DEQ-B scores were
much lower in both groups than W-DEQ-A scores in early
pregnancy. Thus, for most women, delivery was more positive
than expected. According to previous studies [26,47], normal
vaginal delivery leads to the most positive childbirth experi-
ence and emergency CS to the most negative. Among the
women treated by means of group psychoeducation, child-
birth experience was more positive than among those in the
control group in all the delivery mode groups. This may show
that the women in the intervention group were more prepared
for childbirth, even for elective CS.
In our experience, women with severe fear of childbirth do
not often benefit from nor do they even attend normal antenatal
preparatory classes in standard prenatal care, because of the
dissimilarity of feelings towards childbirth (intense fear and
shame). The important role of group psychoeducation is to
share different and contradictory feelings in order to normalise
and diminish feelings of inferiority and lack of dignity, which
are common among women with fear of childbirth [48].
With support, participants can deal with and accept different
emotions and possible setbacks during pregnancy and child-
birth. This, in turn, can help them prepare for a normal delivery,
and it can also help them cope with life’s other problems in
general [34]. Psychoeducative group intervention also included
guided relaxation exercises. The ability to relax helps one to
concentrate on breathing and coping with contractions during
labour and delivery [49], and to accept different emotions
during different phases of labour and delivery [50]. The
ability to relax can also affect the experience of pain and,
according clinical findings, it gives a woman belief in her self-
competence, both of which also lead to a better childbirth
experience [51].
Table 6. Group comparison of fearful childbirth experiences (W-DEQ-B) according to delivery modes.
Intervention (n¼77) Control group (n¼124)
Delivery mode W-DEQ sum score mean ± SD W-DEQ sum score mean ± SD p
Spontaneous vaginal delivery 61.7 ± 32 65.2 ± 25 0.52
Vacuum extraction 73.6 ± 30 82.5 ± 31 0.45
Elective CS 43.0 ± 29 67.1 ± 28 0.08
Emergency CS 73.0 ± 34 88.8 ± 30 0.18
6H. Rouhe et al. J Psychosom Obstet Gynaecol, Early Online: 1–9
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Previous studies have shown the importance of social
support on a woman’s well-being after delivery [52–54] and
our results support this. Single mothers and women with poor
social support are known to be at risk of postnatal depression
[55]. Previous mental health problems are known to predict
mental health problems after a childbirth [18]. Our study
shows that by way of group psychoeducation, we can bring
about a positive effect on depressive symptoms in women
with fear of childbirth. Our results also show an increased risk
for fearful childbirth experience and lower maternal adjust-
ment in women with depressive symptoms during pregnancy.
These results support the idea of routine checking for a
possible history of previous mental health problems during
pregnancy. At the very least, this would include screening for
depression, and, when necessary, referral for adequate treat-
ment. In Finland, use of the EPDS as a screening tool is
already a part of clinical antenatal practice.
Women with fear of childbirth are more vulnerable in
general [56,57], more often have previous mental health
problems [18,19] and more previous traumatizing experiences
[58] and are therefore also at a known risk of developing
PTSD after delivery [7]. Our study population showed a high
prevalence of PTSD profiles compared with the normal
pregnant population (21% of the women who answered versus
1.5–2% in the general pregnant population) [59,60].
Previously it has been shown that postnatal crisis intervention
is not sufficient in preventing PTSD after an emergency CS
[61]. In general, prevention of PTSD by way of a therapeutic
effort before or shortly after a traumatic event is difficult if
not impossible [62].
Limitations
Our findings are not without certain limitations. First, the
questionnaire return rate was quite low. However, our attrition
analysis for drop-outs revealed that, at least in early
pregnancy, the women in both groups had similar levels of
fear of childbirth. Second, the follow-up period was only 3
months after childbirth. We chose this time point on the basis
of information in the literature [63] and to reduce the effects
of later confounders. Third, our data was much skewed, as
only women with very severe fear of childbirth was studied.
Thus, the results cannot be generalised to a complete pregnant
population. Fourth, it was not possible or ethical to carry out a
randomised study comparing group psychoeducation treat-
ment with no treatment at all. Hence, it must be kept in mind
that in this study, control women also received some kind of
treatment for their fear if needed. This may have diminished
the demonstrable treatment effect. Fifth, our sample size does
not make it possible to do any multilevel analysis to compare
the difference between different practitioners. To ensure
fidelity, the original therapists trained all the new psycholo-
gists for this protocol and because of the protocol’s strictness
there should not be too much variability between different
practioners. Officially, fidelity was not assessed. Sixth, the
quite small sample size did not enable us to assess depression
more precisely by using cut-off-scores. At these score levels
of depressive symptoms, this may not be a particularly
clinically relevant finding, as the mean scores were generally
quite low. We need more studies to evaluate the clinical
importance of psychoeducation in preventing depression.
Seventh, our scale for social support was not validated,
although it has been used successfully in previous studies in
Finland [17,64]. The cost-effectiveness of this group psy-
choeducation would be interesting and worth evaluating.
Clinical implications
Our results support the view that there are non-obstetric
aspects in a woman’s history (social support, previous or
current mental health problems, fear of childbirth) that have a
strong effect on well-being after delivery. We should identify
women with problematic backgrounds and offer special
support if needed. Screening for depression by EPDS and
fear of childbirth by VAS should perhaps be part of routine
antenatal care. Nulliparous women with severe fear of
childbirth should be recognised and offered group psychoe-
ducation with relaxation (or other comparable treatment) in
order to relieve their fear and to enable a more positive
delivery experience and better maternal adjustment. Our
protocol might even be adapted for treatment of other risk
groups (e.g. pregnant women with mental disorders). Clinical
guidelines could also be established on how to identify
traumatised women later in the postnatal period and where to
refer them for evaluation and treatment.
Conclusions
In treating nulliparous women with severe fear of childbirth,
group psychoeducation with relaxation exercises improved
maternal adjustment and reduced the risk of fearful childbirth
experiences. The decrease of depressive symptoms continued
throughout the perinatal period, which was not seen in control
women. As clinicians we should pay special attention to
patients with fear of childbirth, especially those with poor
social support or depressive symptoms before or during
pregnancy, to prevent a fearful delivery experience and
postnatal psychosocial problems. Women with severe fear of
childbirth seem to be at a high risk of PTSD following
delivery, even if treated for their fear during pregnancy.
Declaration of interest
The authors report no conflicts of interest.
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äCurrent knowledge on the subject
Mental health problems during and after pregnancy are known to relate to poorer maternal adjustment.
Mental health problems are common in women with fear of childbirth.
Fear of childbirth is known to be a risk factor for traumatizing delivery experience and postnatal depression.
äWhat this study adds
Group psychoeducation improves maternal adjustment and has a positive impact on delivery experience in women
with fear of childbirth.
It is possible that postnatal depressive symptoms in fearful women can be decreased by group psychoeducation.
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