J. Psychosom. ObsM. Gynecol.

18 (1997) 266-272

Reasons for anxiety about childbirth

in 100 pregnant women
B. Sjogren

Center for Women and Children's Health, Department of Obstetrics and Gynecology,
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Karolinska Hospital, Stockholm

Key words: h?xl!rwOF CHILDBIRTH,

hxmY IN PSYCHOLOGICAL
PREGNANCY, DESCRIPTION

ABSTRACT different facets, e.g. fear that labor will be accom-

panied by intolerable pain, or that physical
The aims were to document conscious reasons for anxiety
functions will prove inadequate. There may be
about Childbirth. Pregnant women (n = loo), consecu-
doubt over the competence of the obstetrical
tively referred from antenatal centers to a psychosomatic
hospital staff to provide adequate support during
outpatient clinic because ofextremefear ofchildbirth, were
delivery. Twenty per cent of pregnant women are
interviewed. Three subgroups are described: primiparae
For personal use only.

reported to suffer from'fear of delivery: in 6%, this

(n =36), women with a normal previous delivery
fear is seriously incapacitating'2. In many parous
(n = 18) and women with a previous complicated delivery
women, fear may be due to previous obstetrical
(n = 46). Anxiety over the delivery was related to lack .f
complications, but in other cases the woman may
trust in the obstetrical staz (73%),fear of own incom-
have a history of normal delivery.
petence (65%), j a r of death of mother, infant or both
An associated specific problem is that many of
(55%), intolerablepain (44%) or loss ofcontrol (43%).In
these women request or demand cesarean section
the description ofthe anxiety, more than onefmcould be
(CS). In Sweden during the 198os,there was an
described. A previous complicated delivery predisposed for
apparent increase in the frequency of CS on the
j a r of death (p < 0.001). I n other aspects, the subgroups
grounds of anxiety. From 1983 to 1989, CS per-
were similar: Fear of death in a prrviouc labor was
formed for psychosocial indications increased from
associated with thisfear regadin.. the impending delivery
0.57% to 1.45% of all births'. A similar increase,
(loo%,21%, p < 0.001) and withfear of loss ofcontrol
from 0.2% in 1983 to 0.7% in 1986,was reported in
(61%, 18% p < 0.01). Many women (37%) had
a hospital in Helsingborg'. In another study of the
partners who admitted anxiety over the delimy. Anxiety
women constituting the study group in the present
over childbirth is related to firndamentd human fdlings:
study, 68% requested operative delivery. Finally,
lack oftrust,fear o f f m k incompetence and&ar of death.
afier individualized support, 30%were planned for
Ear ofpain is important but not pre&minant Thc results
an elective CS for psychological reasons. Another
are discussed with r p d to stm, theoretical and psycho-
13 women eventually had CS for other obstetrical
dynamic points qf view.
reasons5. This study used the case-control model,
INTRODUCTION showing that the anxious women had the same
educational level as the controls. Those women
Although a generally recognized phenomenon, who eventually underwent a vaginal delivery had an
anxiety over childbirth may include several obstetric outcome similar to the controls.

correspondenceto:Dr B. SjCigrcn, Center for =men and Children's Health. apartment of Obstetrics and Gynecology. Karolinska
Hospital. S17176 Stockholm

266
 Reasonsfor anxiety about childbirth
A greater understanding of the reasons behind
anxiety about childbirth is also important because
anxiety during labor may upset the woman during
pregnancy and contribute to complications, e.g.
ineffective uterine contraction^".^. The aims of the
present study were, firstly, to define the major
conscious factors behind the severe anxiety over
childbirth in order to find models of treatment and
support during the pregnancy, and, secondly, to
assess the role of previous obstetrical complications.
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The hypotheses were that a pattern regarding the
anxiety would be recognized and that differences
would be found between primiparae and women
with previous complicated or uncomplicated deliv-
eries. Moreover, some guidance for future studies
would be found.
METHODS
The study sample comprised a consecutive series of
100 women referred to the Psychosomatic
Outpatient Clinic of the Department of Obstetrics
and Gynecology, Karolinska Hospital, Stockholm,
For personal use only.
between October 1989and March 1992. They were
referred because of severe anxiety about the
impending childbirth, regardless of the author’s
intention of collecting material for a study. The
women were extremely distressed and unable to
look forward to the arrival of their babies. They had
difficulty in sleeping, nightmares, o r were
preoccupied with thoughts of a surgical delivery.
The gynecologists and midwives providing routine
antenatal care were unable to manage this anxiety.
The time for referral varied between weeks 20
and 35 of gestation. A detailed, systematic obstet-
rical and psychological history was taken by the
author (obstetrician/gynecologist, trained in
psychotherapy). All the women had at least one
consultation of 45-60 min duration with the
gynecologist (author). The median number of
interviews was 3.4 (range 1-10). During the
antenatal psychosomatic treatment at the hospital,
the women continued their contact with the
midwife and obstetrician at their regular antenatal
clinics. In many cases, the obstetrical condition was
discussed with the chief obstetrician at the hospital.
T h e clinical interviews focused on social
situation, and previous and current mental health.
The women’s fears and thoughts about childbirth
were investigated in in-depth interviews and
discussed as intimately as the women allowed. In
J. Psychosom. Obstet. Gynecol.
Sj6gren
the first interview, the women were always asked to
describe in detail their fears about the impending
delivery and to describe previous deliveries.
Sometimes it w a s possible to discuss important
relationships, e.g. with her partner or own mother,
as early as in the first interview. During subsequent
sessions, the information from the first interview
was confirmed and more delicate issues which
which could be raised, such as attitudes towards
motherhood. Many very sensitive issues were
approached indirectly, e.g. asking whether her
mother’s deliveries were difficult or complicated,
which could elicit a response such as ‘she has never
told me anything about it, and I would not like to
discuss such matters with her now either’.
It was observed if the women suffered from a
current emotional crisis, due to a negative life
event. It could be the recent death of a parent,
recent loss of a fetus or serious problems in the
relationship with the partner and doubts about the
future ofthe relationship. It could also be a result of
some earlier psychological crisis, obviously reacti-
vated by the pregnancy and impending delivery, e.g.
death of a parent during the woman’s childhood or
teens, or a particularly painful and complicated
relationship with her own mother. These psychic
problems are defined in the system of psychiatric
diagnosis (DSM W).
The women were assessed as likely to benefit
from psychotherapy, and 25 accepted and under-
went conventional psychotherapy5. Important
information was also obtained during these psycho-
therapy sessions and reported at regular meetings
between the therapist and the psychosomatic
gynecologist. All information was written up
systematically in detailed records, in order to
facilitate follow-up. The records were stored
confidentially, separate from the ordinary medical
records. After the delivery of the 100 women, the
data from the psychosomatic records were
analyzed. The study was inspected by the Ethics
Committee of The Karolinska Hospital.
Statistics
For comparison between subgroups of the sample,
non-parametric methods, Chi-square test, Fisher’s
exact probability test9, and Chi-square test for exact
significance testing of heterogeneity for ordered
categorical datalo were applied. All tests were two-
tailed.
267
 Reasonsfor anxiety about childbirth

RESULTS crises. Of the 35 women who suffered from a

Social s t a t u s
Generally, the social status of the women was
characterized by a high frequency of stable
partnership (92%) and employment (86%).
Obstetrical history
The obstetrical history showed that most of them
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current crisis, about half (16 women) were among
those who had previous mental problems.
The women tended to give one or several major
reasons for fear (Table 2). Seventy-three per cent
stated lack of trust in the attending obstetrical staff
during delivery: 31% did not expect to be given
sufficient support, and 42% feared that they would
not be allowed to retain control Over important
decisions (no differences between the groups, data

had given birth, with a high frequency of previous
complications (Table 1). The results are presented
for three groups, primiparae (n = 36), women with
a normal delivery (n=18) and women with a
complicated delivery (n = 46). The subgroups were
similar in all but one aspect: significantly more of
the primiparous women had had a previous
voluntary abortion (Table 1).
Major reasons for fear of delivery and
psychological health
Previous psychological problems (e.g. periods of
For personal use only.
not presented in table). The next most fiequent
focus of anxiety, reported by 65%, was that they
would prove incapable of giving birth (Table 2).
They fcved that their bodies would be inadequate
or that they would suffer injury (390h),or that they
would not perform well due to psychological
reasons (26%, no significant differences between
subgroups, data not in table). More than half of the
women (55%) described fear of death: their own
(9%) or that of the infant (30%), or of both (16%).
Anxiety about disaster and death was significantly
more frequent among parous women who had
experienced a complicated delivery (p < 0.001).

mental depression, panic disorder) and current
emotional crises due to a recent life event were
identified and are shown in Table 2. There w a s no
significant difference between the subgroups with
respect to previous mental problems and current
Expectations of intolerable physical pain were
expressed by 44% of the women. A similar
proportion feared losing control of the situation, or
the development of total chaos during the delivery,
either on their own part or by the attending hospital

Table 1 0b;tetrical history and social status of 100 women with severe fear of childbirth The three sub-groups are
compared by means ofChi-square test for exact signiiance testing ofheterogeneityfor ordered categorical data9.Siplicant
differenceis considered when p < 0.05
Pnvwus delivny
None Uncomplicated Complicated Toull number p value
(n =36) (n = 18) (n = 46) (n = 100)
Stable partnership 33 13 46 92 NS
Education
university, > 15 years 14 7 17 38 NS
intermediate, 12years 15 5 15 35
elementary, 9 years 4 2 8 14
no answer 3 2 6 11
Involuntary infertility ’ 4 0 3 6 NS
Miscarriage 6 5 8 19 NS
Voluntary abortions 20 4 14 38 0.021
Employed 35 17 44 86 NS
Unemployed 1 1 2 4 -
Parents leave 0 2 8 10 NS
Previous perinatai death or late miscarriage 2 2 9 13 NS
Feeling of chaos in previous delivery - 1 6 7 NS
Fear of death in previous delivery
(infant’s or own) - 1 14 15 0.09 trend
NS. not significant

268 J. Psychosom. Obstet. GynecoL

 Reasonsfor anxiety about childbiflh Sj@ren

Table 2 Age, psychic problems and negative expectations regarding the impending delivery in three subgroups ofwomen
with severe fear of childbirth. One woman could report more than one reason for anxiety The three groups are compared
by means of Chi-square test for exact significance testing of heterogeneity for ordered categorical data9
Previous deliwry
None Uncomplicated Complicuted Total number p value
(n = 36) (n = 18) (n = 46) ( n = 100)

Age 31.92 33.4 32.9 32.8 NS

(SD 5.5) (SD5.9) (SD4.4) (SD 5.1)
Current psychic crisis 14 6 15 35 NS
Previous psychic problems 12 5 15 32 NS
The future delivery will imply
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lack of trust 24 12 37 73 NS
incompetence of giving birth 24 10 32 65 NS
fear of death 15 4 36 55 <0.001
intolerable pain 17 8 19 44 NS
loss of control 17 4 22 43 NS
NS, not significant

sta& Anxiety over physical pain and loss of control,
bodily incapacity or injury, and fear of poor
performance were similar in the groups (Table 1).
Pronounced ambivalence about the maternal role
was indicated by 21 women. Twenty-nine women
For personal use only.
control (58% and 29%, respectively, p c 0.05, data
not presented in table). The women who had felt
anxiety about death more often had a partner who
was afraid of the delivery (61%, 18%, respectively,
p < 0.01). However, these women reported a lower,

knew that one or more of their own mother's
deliveries had been complicated or difficult (not in
table).
Partner's role
The partners of more than half of the women
(55%) participated in the discussion about the
delivery. Thirty-seven per cent had a partner who
frankly admitted his own anxiety over the impend-
ing delivery, and 22% a partner who requested or
demanded CS. The partners of the women who
had experienced a previous complicated delivery
were significantly more often anxious than the
partners in the other subgroups (p = 0.044, data not
presented in table).
Influence of anxiety about death during a
previous delivery
Some differences were found between the parous
women who had felt anxiety about death during
previous childbirth and those who had not: the
former were - not unexpectedly - more frequently
preoccupied with this fear in relation to the coming
delivery (100% and 21%, respectively, p c 0.001).
They also more frequently reported fear of loss of
not statistically significant frequency of expectation
of intolerable pain than the other women (33%and
54%, respectively, p = 0.08). They also had a lower
frequency of negative expectations of injury or
physical inadequacy than the other women (30%
and 46%, respectively, p = 0.1). These differences
did not approach significance. Of those who had
actually experienced perinatal death, 82%, but not
all, described anxiety about death in the previous
delivery.
DISCUSSION
As most pregnant women are preoccupied with the
delivery during their entire pregnancy, and most
intensively during the final trimester", this must be
regarded as a normal phenomenon. However, the
fear described by the women in the present study,
so extreme that it could not be managed by routine
antenatal care, must be regarded as a condition
different from the normal emotional preparation
for childbirth. The present study showed firstly that
in a consecutive series of 100 women with 'fear of
childbirth, almost half (46%) had had a previous
complicated childbirth. Secondly, a number of
different contents of the fear were elicited: 73% of
the women reported lack of trust about the

J. Psychosom. Obstet. Gynecol. 269

 Reasom$r anxiety about childbirth
obstetric team and their providing adequate
support, and 65% of the women feared that they
would prove physically or mentally incapable of
giving birth. Fear of death was expressed by 55%,
loss of control during delivery was feared by 44%
and expectation of intolerable pain was expressed
by 43%. Fear of death was significantly more
frequent among those who had had a previous
complicated delivery Otherwise, there was a great
similarity between the subgroups.
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The results are in accordance with the findings of
an earlier Swedish study reporting that 80% of the
women with fear of childbirth had a history of a
complicated previous delivery4. Another study
found a correlation between vaginal or operative
interventions and disappointment over deliverygf.
All these data justify the application of the stress
theory, including the concept of post-traumatic
stress disordeP. A recent Swedish study found that
76% of women who had undergone emergency CS
had experienced their delivery as a traumatic event.
A completely developed post-traumatic stress
disorder could not be identified, but 33%ofwomen
For personal use only.
were found to suffer from post-traumatic stress
reactions 6 weeks after an emergency CS". The
present study, showing that the women with a
previous complicated delivery more often had fear
of death regarding the future delivery and that this
fear was correlated to a similar experience in a
previous delivery, indicated that their anxiety might
be related to the stress disorder.
Complicated deliveries do not always seem to
result in long-standing severe reactions''. It may
therefore be assumed that the anxiety of the women
with a complicated previous delivery had some
additional psychological determinants. This
assumption is supported by the finding that a great
propomon of parous women with anxiety about
childbirth had already been anxious during the first
pregnancyI5. Regarding women with a normal
previous delivery and nulliparous women also, the
underlying reasons for anxiety could be elicited by
investigating the individual personalities and life
experiences and by applying modem stress theory
as well as the psychoanalytic model. A previous
delivery might have been diagnosed as normal, but
the women could have experienced it as a traumatic
event In a study of victims of t d i c accidents, the
intensity of the stress reaction correlated to the
perceived seriousness of the trauma but not to the
objective seriousnessg6.Again, in accordance with
270
sj*m
this study the stress theory might be applicable in
cases of fear of childbirth, not on the objective
trauma but on the perceived trauma of a previous
delivery.
As described elsewhere, the women in the
present study had a significantly higher frequency
of previous psychological problems than the
controls, indicating a greater vulnerability5.
Previously, negative experience of childhood and of
sexuality has been associated with fear of
childbirth". The findings of lack of basic trust and
fear of death were central themes of the anxiety in
the present study Recently, similar results regarding
lack of trust were obtained from about 33 women
with anxiety over ~hildbirth'~. In comparison, a
s t u d y of 122 non-selected pregnant women found
that the majority denied fear of feeling helpless and
misunderstoodI2.In cases where no traumatic event
could be identified, other theories might be useful
and could be discussed in order to understand the
psychological determinants of intense fear of
childbirth. One of them, the psychoanalytical
theory, has proposed that all fear of childbirth might
be expressions of a deep fear of death which has
been transmitted through many generationsls. The
fears, however, might be considerably reinforced by
individual experiences in early childhood, which
made the women particularly vulnerable to the
inevitable fears during pregnancy. If she, as an
infant herself, did not meet a 'good enough holding
envir~nment"~, lack of trust might develop. The
fear of loss of control might indicate a similar
feeling of emotional and physical insecurity In
cases where these theories were applied, the stress
theory is not contradicted. The women might have
experienced traumatic events during other deliveries.
A complicated attitude towards delivery might
depend on ambivalence towards childbirth and
might increase a woman's anxiety during preg-
nancy. Women may feel various degrees of ambi-
valence towards accepting the maternal role and
some ambivalence might be naturalgllO.Twenty-
one per cent of the women in the present study
admitted a considerable ambivalence towards
reproduction. Moreover, the primiparae in the
present study were older (mean 32 years) than the
average primigravidae in Sweden (mean 26.1
yearsf') and they had signlficandy more o k n had a
previous voluntary abortion, which might indicate
ambivalence. A strong ambivalence in primipane
could be understood in terms of psychoanalytical
J. Psychosom. Obstet Gynecol.
 &asonsfor anxiety about Childbirth Sjijgren

theories maintaining that women might be afraid of Conclusions

their reproductive capacity. This fear might be due
Almost half of the women consulting the psycho-
to the conflicting positive and negative memories of
somatic gynecologist for severe anxiety of
her own motheP. This conflict might give rise to
childbirth had experiences of previous complicated
complicated feelings during pregnancy as the
deliveries. Five major foci of anxiety were
woman faces the role of becoming a mother herself:
identified; firstly, lack of trust in obstetrical staff’s
The social support by a partner is important in
willingness and ability to provide adequate support,
stressful life situations, in accordance with stress
and secondly, the fear of proving physically and
theory as well as the psychoanalytic model. In the
mentally inadequate during labor. The third major
present study, 92% of the women had stable
reason was fear of survival. Fear of pain, the fifth
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partnerships. The partner’s anxiety might have been

focus was important, but not the most frequent
of considerable importance, as indicated by the data
cause. The different foci of anxiety were similar in
on men’s anxiety (37% were anxious about the
women waiting for their first child and women
delivery) and requests for CS (22%). Although it is
with previous deliveries, complicated or normal,
difficult to separate a partner’s own anxiety from
with one exception: greater frequency of fear of
sympathywith his wife’s feelings, it is quite possible
death among women who had had a previous
that an anxious partner might have difficulties in
complicated delivery. The anxiety of women with
providing support. Also, the male partner has
previous complicated deliveries might be explained
personal experiences, e.g. traumatic events, which
by modern stress theory. In addition, psychoanalytic
might influence the couple’s emotional situation.
theories of basic trust and female development can
Female development is also related to the
be taken into account in understanding anxiety
prevailing cultural ideology regarding gender roles.
associated with childbirth. These foci could be used
Feminist authors have observed that the differences
in the psychological support given to women with
For personal use only.

between female and male biology and psychology

fear of childbirth and for design of future studies.
have been described as shortcomings in females.
The life-style, emphasizing ‘masculine skills’
accompanied by financial advantages, may be in ACKNOWLEDGEMENTS
conflict with the women’s reproductive periods and
The author is grateful to Associate Professor €?
increase anxiety2). Sixty-five per cent of the women
Thomassen for advice and support during the
in the present study thought that they would not be
design of the study, and to Professor B v Schoultz
able to perform satisfactorily when giving birth,
for excellent supervision of preparation of the
which might be interpreted both as fear of female
manuscript. Financial support was received from
inadequacy and as a general need to perform well.
The Swedish Society of Medicine ‘and The
Karolinska Institute.

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