critical appraisal of research evidence

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The Arts in Psychotherapy

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Research Article

Group art therapy for the management of fear of childbirth
Ceren Sezena, Barış Önen Ünsalverb,⁎

a Üsküdar University, Clinical Psychology Master’s Program, Istanbul, Turkey
b Üsküdar University, Istanbul, Turkey

A R T I C L E I N F O

Keywords:
group art therapy
fear of childbirth
art therapy
tocophobia

A B S T R A C T

Background: Even though most pregnant women might have some concerns regarding the mode of delivery some
women may experience a heightened fear of childbirth (FOC), which may make pregnancy a disturbing and
discomforting experience for them. Clinical FOC leads to an increase in C-section demands and the ratio of C-
section births. Therefore, management of FOC is essential for improving public health. The objective of this pilot
study was to evaluate the efficacy of group art therapy for the management of FOC.

Methods: To understand the effectiveness of group art therapy, we designed a quantitative study. The po-
pulation studied was pregnant women with subjective complaints of FOC attending an outpatient pregnancy
follow-up clinic. Effectiveness of group art therapy intervention was assessed in comparison to group psy-
choeducation for FOC. The primary outcomes of the study were determined as Wijma Delivery Expectancy/
Experience Questionnaire Version A (W-DEQ) scores below 37, Beck Depression Inventory (BDI) scores below 14
and the Beck Anxiety Inventory (BAI) scores below 10 at the end of the 6th session for the art therapy group. We
expected to find significant differences in the primary outcome measures between the two groups. The secondary
outcome of the study was the difference between the two groups regarding the mode of actual delivery. 30
women volunteers in the third trimester of pregnancy attending a public women’s hospital with moderate levels
of FOC were included in the study. They were randomly distributed to 2 groups. The first group (n = 15)
received six sessions of group art therapy. The second group (n = 15) received six sessions of psychoeducation
for FOC.

Results: By the end of the six weeks, Beck depression scale (BDS) scores, Beck Anxiety Scale (BAS) scores, and
W-DEQ scores decreased significantly in the art therapy group in comparison to the psychoeducation group
(p < 0.001). FOC was considerably decreased in the art therapy group in relation to the control group at the end
of the treatment. Most of the women (n = 12) in the art therapy group had natural deliveries while those in the
psychoeducation group had C-sections (n = 10).

Conclusions: Our findings suggest that art therapy is an efficient method for reducing clinical FOC and levels
of anxiety and depressive symptoms in pregnant women in the final trimester. This arts therapy programme
enabled these shifts in behaviour by helping women face and express their fears through their artwork (drawing)
and then gain control over their fears (mandala-making, puppet-making, taking photographs and collage-
making) within a secure base and an on-going social support system provided by the group structure. Group art
therapy seems to be a cost-effective therapeutic approach for targeting a larger number of people in a limited
time with a limited number of therapists.

Introduction

Even though most pregnant women might have some concerns re-
garding the mode of delivery some women may experience a heigh-
tened fear of childbirth (FOC), which may make pregnancy a disturbing
and discomforting experience for these women. FOC may be accepted
as a natural reaction especially in nulliparous women. What is called
normal fear would not affect the everyday life of the woman and

decisions regarding the delivery method. There is no consensus on the
definition of FOC. Some authors used the term “tocophobia” to reduce
this confusion (Hofberg & Brockington, 2000). They defined tocophobia
as a condition where the woman had recurrent and intrusive thoughts
about delivery and its possible complications such as harming the baby
or not being able to give birth at all, and subsequent avoidance of
childbirth. In a recent review “clinical FOC” is described as a disabling
fear that intrudes with general functioning affecting the occupational,

https://doi.org/10.1016/j.aip.2018.11.007
Received 28 November 2017; Received in revised form 31 July 2018; Accepted 24 November 2018

⁎ Corresponding author at: Altunizade Mahallesi, Haluk Türksoy Sk. No: 14, 34662, Üsküdar, Istanbul, Turkey.
E-mail address: [email protected] (B.Ö. Ünsalver).

The Arts in Psychotherapy 64 (2019) 9–19

Available online 26 November 2018
0197-4556/ © 2018 Elsevier Ltd. All rights reserved.

T

domestic and social life of the woman, and in some cases meeting the
definition of specific phobia (Nilsson et al., 2018). In this article, we
chose to use “fear of childbirth (FOC)” instead of tocophobia because it
is the most commonly used term for this condition in the available
literature.

FOC may affect a woman’s general well-being and have negative
consequences on the mode of delivery (Saisto & Halmesmaki, 2003).
The woman may have a fear of giving birth even before getting preg-
nant. However, the degree of the fear begins to increase by the twen-
tieth week (Rouhe, Salmela-Aro, Halmesm, & Saisto, 2009). Prevalence
of FOC depends on cultural variables, the period of pregnancy, and the
differences among methods of detecting FOC. However, it is estimated
to be observed by 15–20% on average (Fenwick et al., 2009).

The primary reasons for FOC are hearing others’ frightening de-
livery stories (Melender, 2002), history of obstetric complications
during delivery (Størksen, Garthus-Niegel, Vangen, & Eberhard-Gran,
2013), lack of knowledge regarding childbirth (Cleeton, 2001), fear of
labor pain (Aksoy, Aksoy, Dostbil, Çelik, & Ince, 2014), inadequate
psychological and physical support from the spouse throughout preg-
nancy and during birth (Saisto, Salmela-Aro, Nurmi, Könönen, &
Halmesmäki, 2001), lack of trust toward medical staff (Sjögren &
Thomassen, 1997), lack of psychological support provided by the ob-
stetrician, a history of anxiety disorders or depression (Saisto et al.,
2001), sexual abuse (Boorman, Devilly, Gamble, Creedy, & Fenwick,
2014), lower levels of education, young age pregnancy, unemployment,
and low levels of income and social support (Boorman et al., 2014).

Untreated FOC in pregnancy may both prolong the delivery and
increase the subjective experience of labor pain which might result in
the registration of negative memories in the mother regarding birth
(Goodman, Mackey, & Tavakoli, 2004). This disturbing delivery ex-
perience may affect the mother’s future choice of birth method. Pro-
longed delivery may also result in medical decisions such as epidural
anesthesia use, induction, assisted childbirth and emergency C-sections
(Adams, Eberhard-Gran, & Eskild, 2012; Sydsjö et al., 2013). FOC also
poses a risk for premature and postmature births and may cause post-
traumatic stress disorder (Korukcu, Kukulu, & Firat, 2012) or post-
partum depression, sexual dysfunction and lack of harmony in the
mother-baby relationship (Fisher, Hauck, & Fenwick, 2006).

Therefore, treatment of FOC is essential to prevent the aforemen-
tioned negative consequences on the child and the mother. The objec-
tive in treating FOC is to ensure a comfortable experience of pregnancy,
facilitate the adaptation to motherhood and make sure that the mother
feels well in the postpartum period. The treatment options to manage
FOC include breathing techniques, hydrotherapy, hypnosis, doula as-
sistance, training for childbirth, psychoeducation (Rouhe et al., 2015;
Toohill et al., 2014) psychotherapy that focuses on FOC and the four-
step PLISSIT (Permission, Limited Information, Specific Suggestions,
Intensive Therapy) model that has been adapted to FOC, which is
composed of permission for individual sexual issues, limited informa-
tion, specific suggestions, and intensive treatment when needed (Saisto
& Halmesmaki, 2003).

The likelihood of having C-section birth is 5.2 times higher among
pregnant women with FOC (Sydsjö et al., 2013). Women requesting C-
sections may change their minds and prefer vaginal birth after receiving
psychotherapy for FOC (Ryding, 1991; Sjögren & Thomassen, 1997). In
a study, it was found that a simple telephone psychoeducation inter-
vention delivered by midwives to pregnant women with high levels of
FOC (W-DEQ A ≥ 66) was effective in decreasing levels of fear (Toohill
et al., 2014) and the rates of C-sections (Fenwick et al., 2015).

Art therapy seems to be a promising method for managing various
antenatal and postnatal psychological problems such as depression,
birth trauma or FOC (Hogan, Sheffield, & Woodward, 2017). Art
therapy with pregnant women has been shown to create positive effects
such as relieving inner tension and decreasing levels of stress, anxiety
and depression (Chang, Chen, & Huang, 2008; Demecs, Fenwick, &
Gamble, 2011; Shin & Kim, 2011; Swan-Foster, 1989; Swan-Foster,

Foster, & Dorsey, 2003). A pregnant woman goes through prenatal
bonding before birth and separation and postnatal bonding after birth.
However, some women may experience difficulties while going through
these stages which might cause psychophysiological dysfunctions in the
mother and the infant. Art therapy may help the woman to experience
prenatal bonding and expected separation and postnatal bonding
through the therapy process and the artwork that is produced. Art
therapy encourages the pregnant woman to reconstruct her fears and
conflicts into new representations that empower the woman as a mo-
ther (Swan-Foster, 1989). Negative emotions are alleviated and re-es-
tablished in a healthy bonding experience.

One of the first reports of art therapy in pregnancy was by Nora
Swan-Foster on four pregnant women. The researcher utilized drawing
self-portraits, fear, transformation of fear and closing mandala. These
women gained increased self-awareness and decreased energy invest-
ment in fears which resulted in higher self-esteem (Swan-Foster, 1989).
Demecs et al. (2011), reported their observations regarding Creative
Activities in pregnancy program (CAP-Program). The program con-
sisted of six two-hour sessions that used singing, dancing, storytelling
and making an art project for the baby. Interviews with seven women
who attended this program were reported. The women in the study did
not have clinical FOC. Art therapy worked as a basis for social support
for them. The participants reported increased connection with self, with
the baby and with each other. They found balance in pregnancy and
balance in being ready for the upcoming birth and they took the bal-
ance home (Demecs et al., 2011). Lee et al. (2014) presented a poster on
an art therapy intervention study on 49 high-risk pregnant women who
were hospitalized. The number and structure of sessions were not
specified because this was a poster presentation. The method used was
drawing. They found that stress management, emotional expression and
verbal communication were improved with art therapy. In the study by
Wahlbeck, Kvist, and Landgren (2017), 21 women with severe FOC as
measured by WDE-Q received five sessions of either individual or group
art therapy. 19 of these women were interviewed three months after
birth. 15 had vaginal delivery. The interviews with the women revealed
that they benefited from art therapy in terms of decreased fear and
increased self-confidence, strength and hope. Their common difficulties
were feelings of carrying a heavy baggage and fear of hospitalization
process and physical damage. They acquired new insights and abilities.
Art therapy helped them deposit their heavy baggage and facilitate
attachment to the baby. The method that was used in the study was
painting. Although limited in number, these studies support the efficacy
of art therapy for the management of psychological problems in preg-
nancy.

The Turkish government has been trying to decrease the high rates
of C-sections in Turkey by law, threatening the doctors to impose fines
(Letsch, 2012). However, according to an article by Betran et al. (2016)
the rate of C-sections is still reported to be high in Turkey (47, 5%).
Accordingly, we aimed to find a cost-effective and practical psy-
chotherapeutic approach to manage FOC. In the light of all of the
available data on art therapy, we hypothesized that art therapy would
meet our expectations. The primary purpose of this pilot study was to
investigate the efficacy of group art therapy in comparison to a psy-
choeducation group for the management of FOC. Turkey is a highly
populated developing country. The number of available psychothera-
pists is low compared to the population in need. So, we chose the group
therapy approach as a cost-effective method suitable for middle and
low-income countries. Our target population was selected from among
pregnant women attending a general outpatient pregnancy follow-up
clinic. We expected these women to be unfamiliar with psychological
concepts and practices of psychotherapy. So, we hypothesized that art
therapy would benefit these people without forcing them to speak their
minds but instead encouraging them to reconstruct their fears and
conflicts into new representations that would empower them as a mo-
thers (Swan-Foster, 1989). We tried to prepare a short-term but intense
treatment plan that targeted nearly all of the issues that might have

C. Sezen and B.Ö. Ünsalver The Arts in Psychotherapy 64 (2019) 9–19

10

resulted in or complicated FOC. We thought that psychoeducation
would provide a suitable comparison group for art therapy because it is
an approach that is commonly used with pregnant women with FOC
(Rouhe et al., 2015).

Methods

To understand the effectiveness of group art therapy, we designed a
quantitative study. According to the PICO framework (Eden, Levit,
Berg, & Morton, 2011) the studied population was pregnant women
with subjective complaints of FOC attending an outpatient pregnancy
follow-up clinic. The effectiveness of the group art therapy intervention
was assessed in comparison to group psychoeducation for FOC. The
primary outcomes of the study were determined as Wijma Delivery
Expectancy/Experience Questionnaire Version A (W-DEQ) scores below
37, Beck Depression Inventory (BDI) scores below 14 and the Beck
Anxiety Inventory (BAI) scores below 10 at the end of the 6th session
for the art therapy group. We expected to find significant differences in
the primary outcome measures between the two groups. The secondary
outcome of the study was the difference between the two groups re-
garding the mode of actual delivery.

Participants

The two groups were formed from consecutive pregnant women
who had applied for a pregnancy training program that was run at a
specialized Women’s and Children’s Disease Training and Research
Hospital. We briefly explained the study to all pregnant women who
attended the hospital between January 25 and February 9, 2016. A full
description of the study was given to women who were interested, and
15 women who were eligible for the study and who gave informed
consent were chosen for the art therapy group. A control group was
formed by 15 women who wanted to attend the hospital’s pregnancy
training program. Informed consent was also obtained from the control
group participants. The study took place between February 12, 2016,
and March 18, 2016. Inclusion criteria were: (1) 28–32 weeks’ gesta-
tion, (2) complaints of fear of giving birth, (3) not having participated
in any childbirth training before, and (4) age older than 20 years.
Exclusion criteria for the study were: (1) risky pregnancy diagnosis, (2)
hearing or visual impairment (3) any psychiatric or neurological diag-
nosis, (4) already being involved in a psychotherapeutic process, and
(5) using psychiatric medicine.

Group art therapy procedure

The study lasted six sessions, which was based on a previous study
of six-session group therapy on FOC (Rouhe et al., 2009). Psy-
chotherapy for issues that are specific for and arise during pregnancy
has to be time-limited. Each session was 130 min long.

The structure of the art therapy sessions was as follows: preparation
for work (15 min), a warm-up stage that featured sharing the previous
week’s well-being and unshared products (15 min), a declaration of the
new session’s topic and activity (10 min), the application of artwork
(40 min), sharing the final product (40 min), and closure (10 min). The
session structure was adapted from Liebmann and ebrary Inc. (2004).

The scientific background for the different art therapy techniques that were
chosen for each session

Listening to music and singing
In all six sessions, the group members listened to music and sang

together. Studies have shown that activities of listening to music and
singing activities contribute to the development of trust and commu-
nication within a group. Music has positive effects on fear, anxiety, and
depression in pregnant women (Corbijn van Willenswaard et al., 2017).
A study by Shin found that future mothers who listened to music for

25 min/day for 30 days in a group setting became more self-confident
by being supported by other group members, their maternal bonding
improved, and their anxiety was reduced (Shin & Kim, 2011). A two-
week study conducted by Chang et al. (2008) with a treatment group of
116 and a control group of 120 used music. As a result of the study, it
was observed that the levels of depression and anxiety in the future
mothers were reduced. Toker and Komurcu (2017) studied the effects of
Turkish classical music on women with pre-eclampsia. 70 women with
pre-eclampsia were randomized into groups of either 30 min of rest or
to 30 min of listening to music. In comparison to the control group, the
women who listened to the “nihavend” and “buselik” modes of classical
Turkish music 5 days before and 2 days after labor had increased sa-
tisfaction with nursing care and decreased blood pressure. Classical
Turkish music had positive effects on fetal movements and fetal heart
rate. In a study that was conducted in Taiwan, 296 pregnant women
were randomized in an experiment group of listening to 30 min of pre-
recorded music compact discs (CD) in addition to routine prenatal care
(n = 145) and a control group that received routine prenatal care
(n = 151) (Chang, Yu, Chen, & Chen, 2015). The tempo of the music in
the CDs were chosen to imitate the human heart rate of 60–80 beats/
min. The trial lasted two weeks. Listening to music reduced pregnancy-
related stress levels as measured by the Pregnancy Stress Rating Scale
(PSRS). In another recent study, listening to pre-recorded music com-
posed for the pregnancy over a period of twelve weeks reduced anxiety
and depression symptoms significantly in comparison to a control group
of pregnant women who sat quietly and undisturbed (Nwebube, Glover,
& Stewart, 2017).

Mask-making
Masks are a form of therapy and treatment, and they are the means

by which one freely expresses their identity within a group and reveals
their social roles. Group members are included in the group process
without knowing each other, and each member may not have the same
ease of expressing themselves or may hesitate to reflect themselves as
they are. Masks provide this freedom to individuals (Trepal-Wollenzier
& Wester, 2002). Moreover, formation of group cohesion is based on
sharing among group members, trust and honest expression. Mask-
making was chosen for the members to express themselves honestly
without making them feel naked, so that the group is allowed to pro-
gress and develop.

Drawing
Emotions and thoughts are reflected as concrete signs through

painting. Drawing is useful for enhancing self-reflection and promoting
personal growth (Binson & Lev-Wiesel, 2017). Use of drawing has been
utilized in previous studies of art therapy with pregnant women (Swan-
Foster, 1989; Swan-Foster et al., 2003; Demecs et al., 2011; Wahlbeck
et al., 2017). Fears surrounding birth may be expressed through
drawing as shown by a study with 60 pregnant women with different
degrees of prenatal problems by Foster, Foster, and Dorsey (2003).
Cohen-Yatziv, Snir, Regev, Shofar, and Rechtman (2018) examined the
drawings of 11 primigravidae who had depressive symptoms. Ac-
cording to the phenomenological analysis of the drawings, color use
was limited to a combination of blue and yellow, a rectangular page
format instead of circular or oval page formats was preferred more
commonly, surroundings and details were lacking in the drawings, and
the represented objects were either separated or there was an absence
of holding. Some common themes that emerged were feelings of re-
duction, inadequacy and simplification, and internal conflicts between
positive and negative feelings towards motherhood and separation. The
study suggested that drawings may provide valuable information for
diagnosing the psychological difficulties encountered by pregnant
women that are not verbalized or that are not yet clinically dysfunc-
tional. By using drawing, we aimed to help bring forward unspoken or
unrealized fears of the women.

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Mandala-making
Mandalas are a practical way to calm an individual’s mind and de-

crease fear and anxiety (Curry, Kasser, & Galesburg, 2005; Drick, 2014).
In a study, mandala drawings were found to be more useful in reducing
stress than freehand drawing practices (Schrade, Tronsky, & Kaiser,
2011). In another study with 67 adults, mandalas were an effective tool
in transforming negative moods into positive moods (Babouchkina &
Robbins, 2015). Chetu (2015) used mandala-making as a part of a four-
session program designed for pregnant women to optimize prenatal
attachment. Mandala-making was chosen to encourage the women to
think about their resources and emotional challenges and the effects of
these on their relationship with their fetus in pregnancy. However, the
effects that are specific for mandala-making were not mentioned in the
article. Mandala-making was chosen because there was a need for a
practice that would help restructure and reintegrate the fears and other
emotions that would have been expressed in the previous session.

Puppet-making
Making puppets and making them talk encourages people to so-

cialize, express themselves and resolve emotional conflicts. A puppet is
a projective tool, encouraging the individual to uncover fears, concerns,
and conflicts. Moreover, individuals embody their dreams and desires
through puppets, so, they have the opportunity to see what they wish to
see (Bender & Woltman, 1936). Throughout pregnancy, women dream
of what kind of a baby they will give birth to. Expectations arise in
many areas from the physical traits of the baby to the way it is raised.
The first encounter is a surprise. For this reason, it is important to re-
hearse this encounter and see in advance what future mothers expect
from it and can offer to their babies. One of the most fundamental fears
of a woman about birth is the question of “Will my baby be fine?”. We
wanted to address women’s concerns regarding the baby by the way of
puppet-making.

Taking photographs
Converting something into a photograph is the equivalent to

wanting to own it. The individual has the opportunity to reflect their
feelings while establishing a relationship between themselves and the
outside environment. The events or situations that are saved in pho-
tographs depend on the desire of the person (Sontag, 1973). In a pho-
tography study with adults, it was found that the participants were
positively affected in aspects such as trust, self-worth, and honesty
(Glover-Graf & Miller, 2006). The purpose of photography being used as
an art tool in therapeutic communication is to develop self-confidence,
self-expression and general well-being (Weiser, 2001). As birth ap-
proaches, women need courage and to trust themselves in the act of
giving birth.

Collage-making
The product that is created in a collage study depends on the ex-

periences that emerge until that moment and feelings at that moment.
Decisions made during the study process ensure that autonomy is re-
gained. Experiencing this autonomy and supporting personal commit-
ment reveal the changes associated with the topic of the study. At the
end of the study, individuals feel themselves balanced (Hopf, Elbing,
Heußner, & Büssing, 2014). It is important that at the end of the studies
that pregnant women depart from the group structure and return to
their individual structures and regain their own autonomy. These col-
lages also reveal what pregnant women have gained throughout these
six sessions before they leave the group.

Psychoeducation structure

The structure of psychoeducation sessions was as follows: the warm-
up stage that featured sharing of the previous week’s well-being
(20 min); a declaration of the new session’s topic (10 min); sharing of
every woman’s personal thoughts, feelings, and significant memories
regarding the topic (30 min); psychoeducational information given by
the therapist regarding the topic (40 min); sharing of new thoughts or
feelings after psychoeducation (20 min); and closure (10 min).

The same therapist led both groups. She conducted both groups in
the same room but on different days of the week. She provided a
comfortable environment for the pregnant women, prepared the ma-
terials, and gave technical information when necessary. The structure of
the sessions and the materials used are summarized in Table 1.

Measures

A sociodemographic questionnaire including age, gestational age,
educational status, work status, and childbirth experience (primipara or
multipara) was completed by the women before the study.

Both the control group and the study group were assessed using the
W-DEQ version A, BAI, and the BDI before starting the group therapy
process (T1), after the third session (T2), and after the sixth session
(T3).

We measured FOC using W-DEQ version A. The scale had 33 items,
with scores from 0 to 5 for each. The higher the scores, the more fearful
the pregnant women were about childbirth. Low fear was defined by a
WDEQ-A score that was equal to or lower than 37, moderate fear was
defined by a score between 38 and 65, and a high level of fear was
defined by a score that was equal to or higher than 65 (Wijma, Wijma,
& Zar, 1998) In the Turkish validity and credibility study of the scale,
Cronbach’s alpha was determined as 0.92 (Korukcu et al., 2012).

The BAI is a 0–3 Likert scale of 21 questions developed by Beck to
determine the severity of anxiety symptoms (Beck, Epstein, Brown, &

Table 1
Structure of psychotherapy sessions.

Sessions Content Art therapy group Control group

1st session Meeting of the group members. Forming group rules. Introduction to the group process
and setting goals.

Mask making
Listening to music and singing

Pen and paper

2nd session Describing the features of fear of giving birth. Explaining the reasons underlying fear of
giving birth. Exploring personal causes for each woman for their fear of giving birth.

Drawing
Listening to music and singing

Book reading (Birthing from within by
Pam England)

3rd session Management of fear by becoming aware of different solutions and choosing one that
suits best for the individual. Practicing mental imagery guided relaxation breathing.

Mandala making
Listening to music and singing

Book reading (Hypnobirthing by
Marie F Mongan)

4th session Bonding with the baby exercise. Defining the attachment
theory and features of secure and non-secure attachment. Explaining the effects of skin
to skin touch on the interaction between the mother and the baby.

Puppet making Listening to
music and singing

Pen, pencil, powerpoint presentation

5th session Exploring the perceptions of each pregnant women regarding giving birth to a child.
Talking about personal thoughts on concepts of success and failure. Encouraging self-
compassion, self-confidence, and courage.

Taking photographs Listening to
music and singing

Pen, paper

6th session Clarifying the expectations of the woman from their spouses, family, and medical staff
during their delivery. Going through personal gains attained during therapy.
Monitoring general mood of the pregnant woman. Closing the group work.

Making collage paintings
Listening to music and singing

Pen, paper

C. Sezen and B.Ö. Ünsalver The Arts in Psychotherapy 64 (2019) 9–19

12

Steer, 1988). The Turkish validity and credibility study of the scale
showed good psychometric properties (Ulusoy, Sahin, & Erkmen,
1998). The total score of the scale varies between 0 and 63. A score of
0–9 points is classified as “normal or no anxiety,” 10–18 as “mild to
moderate anxiety,” 19–29 as “moderate to severe anxiety,” and 30–63
as “severe anxiety.”

The BDI is a self-assessment scale of 21 questions developed by Beck
to detect depression risk and the level of depressive symptoms (Beck,
Ward, Mendelson, Mock, & Erbaugh, 1961). The total score of the scale
varies between 0 and 63. A score of 0–13 points is classified as “no
depression,” 14–24 points as “moderate depression,” and 25 and above
as “severe depression.” The Turkish validity and credibility study of the
BDI showed good psychometric properties (Hisli, 1989).

Statistical analysis

This study used and experimental pre-test (T1), mid-test (T2), and
post-test (T3) control group design. This study used frequencies (N),
percentages (%), means ( ± standard deviation), medians (because the
data was skewed for the quantitative scale scores), and 25% and 75%
percentiles as descriptive statistics. All of the measurements were
computed at T1, T2, and T3. The analysis of the categorical data was
conducted using the Chi-Squared test (Table 3). The data did not
comply with a normal distribution, so, Mann-Whitney U test was used
for the analysis of the independent variables (art therapy and psy-
choeducation) and Friedman two-way ANOVA test was used for the
analysis of the dependent variables (W-DEQ, BAI, BDI scores) (Tables
4–6). The statistical significance level was accepted as p < 0.05.

Ethical considerations

Permission to perform this art group therapy and psychoeducation
study was granted by the Training and Research Hospital that this study
took place, and the study was conducted after approval from the ethical
committee of a Turkish University. The ethical standards of the Helsinki
Declaration were followed. The costs of the research were covered by
the researchers. All the pregnant women gave informed consent before
the study.

Results

Quantitative results

The women in the art therapy group were older (mean = 28,
SD = 4.9) than those in the control group (mean = 26.3, SD = 4.8).
Five women in the art therapy group were housewives, while eight in
the control group were housewives. There were no significant differ-
ences between the groups regarding other demographic characteristics
and their histories of pregnancy (Tables 2 and 3).

At T1, the median BAI scores were 24 and 22 for the art therapy and
control groups, respectively, suggesting moderately increased anxiety.
The median BDI scores at T1 were 23 for both the art therapy and
control groups, indicating moderately depressive symptoms. At T1, the
median W-DEQ scores were 51 and 56 for the art therapy and control
groups, respectively, suggesting moderate FOC. There were no

statistically significant differences regarding the W-DEQ, BAI and BDI
scores between the art therapy and control groups at T1 (p = 0.345,
p = 0.461 and p = 0.653, respectively) (Tables 4–6). At T2, the BDI
scores were found to be significantly lower in the art therapy group
(p < 0.001) (Table 6). At T3, the median BAI and BDI scores for the art
therapy group (8 and 7, respectively) were both below the cut-off
scores. However, the median BAI and BDI scores for the control group
(23 and 21, respectively) were both above the inventories’ cut-off scores
at T3, indicating persistent symptoms of anxiety and depression. The
median W-DEQ score for the art therapy group at T3 was 28, which is
accepted as a low level of fear. The median W-DEQ scores remained
nearly the same at T1, T2 and T3 (56, 55 and 55, respectively) in the
control group, suggesting a sustained moderate level of FOC. At T3, the
BAI, BDI and W-DEQ scores were found to be statistically significantly
lower in the art therapy group (p < 0.001) (Tables 4–6) (Figs. 1–3).

More women in the art therapy group (n = 12) than in the control
group (n = 5) had vaginal delivery (Table 7). The reasons for C-section
in the art therapy group were: baby weighing heavier than 4 kg, fetal
distress and prolonged labor. Ten women in the psychoeducation group
had C-sections. 7 had elective C-sections because of fear of delivery
room, fear of episiotomy, traumatic memory of previous natural de-
livery and fear of harming the baby because the baby was the result of
in vitro fertilization. The remaining 3 C-sections were because of
medical conditions (overweight baby, occipital presentation, non-pro-
gressive labor).

Qualitative findings for the art therapy group

Common concerns of women when they started therapy
Will my baby be healthy? What if delivery harms my baby?
Will I be able to give birth? What if I cannot have a vaginal delivery?

What if I will shout too much?
Will I be able to take care of my baby? Will I be a good mother?
What will the delivery process be like? What if I will be alone during

delivery?
They had imagined the pain associated with delivery as unbearable.

Some women thought they would get so exhausted in labor this would
prevent the baby from being born. Some feared that the birth would
harm the baby.

Common interpretations of pregnant women regarding group art therapy
Nearly all women said they were at first reluctant to start therapy

but admitted that they felt relieved after hearing similar stories from
other women which made them feel supported. Some of them said they
had doubted the efficacy of art in decreasing their fears. However, as
the study progressed, they saw how their fears and conflicts were re-
flected in their artworks. One woman said, “I saw how all emotions

Table 2
Demographic features of the participants.

Art therapy group Control group
Mean SD Mean SD p

Age 28.0 4.9 26.3 4.8 0.354
Number of pregnancy 1.5 0.7 1.3 0.6 0.200
Gestation week 31.2 2.6 31.0 3.0 0.200

*t–test.

Table 3
Demographic features of the participants (Descriptive statistics).

Art therapy
group

Control
group

N % N %

Education High-school 4 26.7 4 26.7
University 11 73.3 11 73.3

Work status House-wife 5 33.3 8 53.3
Working 10 66.7 7 46.7

Place of residency City 15 100 15 100
Type of family extended 3 20 2 13.3

nuclear 12 80 13 86.7
Planned pregnancy? Yes 13 86.7 14 93.3

No 2 13.3 1 6.7
History of miscarriage,

abortion or ectopic
pregnancy

Yes 2 13.3 1 6.7

No 13 86.7 14 93.3

C. Sezen and B.Ö. Ünsalver The Arts in Psychotherapy 64 (2019) 9–19

13

could come to the surface with colors, pictures and music.”

The effects of some techniques on women
Those who were concerned about the safety and health of their baby

regarding the negative effects of delivery on the baby said they bene-
fited the most from the puppet-making. They said that “meeting the
baby through the puppet was like a rehearsal for the real baby.” Most
women expressed intense emotions during the puppet-making session.

Those who were concerned about having disruptions during the
natural course of delivery stated that the mandala technique calmed
them. One participant said “Imagining the vagina as a mandala was
exciting. Every circle that I drew was like the opening of my cervix for
easing the labor, and I got more relaxed with every circle I drew.”

The artwork from the art therapy sessions may be seen in Images
1–4 .

Table 4
Comparison of WDEQ Scores at T1, T2 and T3 in the art therapy and control group.

Art therapy group Control group

Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75 p

T1 51.00 36.00 56.00 56.00 42.00 58.00 0.345
T2 41.00 31.00 46.00 55.00 41.00 58.00 0.004
T3 28.00 21.00 32.00 55.00 42.00 56.00 < 0.001

*Mann Whitney U.

Table 5
Comparison of the BAI scores at T1, T2 and T3 in the art therapy and control group.

Art Therapy group Control group

Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75 p

T1 24.00 23.00 25.00 22.00 21.00 44.00 0.461
T2 20.00 19.00 21.00 23.00 22.00 45.00 0.016
T3 8.00 4.00 12.00 23.00 22.00 45.00 < 0.001

*Mann Whitney U.

Table 6
Comparison of the BDI at T1, T2 and T3 in the art therapy and control group.

Art therapy group Control group

Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75 p

T1 23.00 21.00 24.00 23.00 20.00 26.00 0.653
T2 16.00 14.00 17.00 23.00 21.00 25.00 < 0.001
T3 7.00 6.00 9.00 21.00 19.00 24.00 < 0.001

*Mann Whitney U.

Fig. 1. Change in BAI Scores.
Fig. 2. Change in BDI Scores.

Fig. 3. Change in W-DEQ Scores.

C. Sezen and B.Ö. Ünsalver The Arts in Psychotherapy 64 (2019) 9–19

14

Discussion

This study examined the efficacy of six sessions of group art therapy
in comparison to a psychoeducation group for managing FOC. The
primary outcome of the study was a significant decrease in WDEQ, BAI
and BDI scores in the art therapy group in comparison to the control
group at the end of the treatment. The secondary outcome was in-
creased rates of natural deliveries in the art therapy group (n = 12) in
comparison to the psychoeducation group (n = 5). It may be stated that
significant decrease in WDEQ predicted increased rates of vaginal birth.
This is consistent with previous studies where women changed their
minds about their method of birth after receiving psychotherapy for
FOC (Fenwick et al., 2015; Ryding, 1991; Sjögren & Thomassen, 1997).
The increased vaginal birth rates may be interpreted as evidence of the
efficacy of the group art therapy for managing FOC in our study.

Our findings of decreased anxiety and increased well-being were
congruent with those of previous studies on art therapy for pregnant
women (Swan-Foster, 1989; Swan-Foster et al., 2003; Chang et al.,
2008; Demecs et al., 2011; Shin & Kim, 2011; Chetu, 2015; Wahlbeck
et al., 2017). Most reported art therapy studies used the methods of
music and drawing. In our study, in addition to music, we used other

Table 7
Types of delivery in the art therapy and control groups.

Normal delivery (n) Caeserian section (n)

Art therapy 12 3
Control group 5 10

Image 1. Lower left image is collage work from the 6th week. Other images are from the mandala session drawings on the 3rd week.

Image 2. Drawing from the 2nd week.

C. Sezen and B.Ö. Ünsalver The Arts in Psychotherapy 64 (2019) 9–19

15

techniques such as making masks, collages, puppets, taking photo-
graphs and making mandalas to involve the pregnant women in various
perspectives to be able to address different issues related to FOC.
Therefore, our report seems to be the first study of group art therapy
using different artistic techniques for managing FOC.

The interpersonal neurobiology perspective defines psycho-
pathology in terms of suboptimal integration and coordination in the
neural networks of the brain (Cozolino, 2002). Accordingly, psy-
chotherapy is a way of creating and/or restoring neural network in-
tegration and coordination. Art therapy stimulates both hemispheres of
the brain through sensory, perceptual, emotional and cognitive pro-
cessing and integration is possible with facilitated attention, increased

communication and logical understanding (Hass-Cohen & Findlay,
2015 p.21, p 331). In the light of this knowledge, we propose that the
positive primary and secondary outcomes in just six sessions of art
therapy were the results of multimodal stimulation of the body and the
brain, and we facilitated neural integration by our use of different ar-
tistic techniques in each session.

The engaging attitude of the art therapist must have also helped to
build a therapeutic alliance with the women. One important factor
contributing to change in psychotherapy is the therapeutic alliance
between the therapist and the patient. The warmth, empathy, en-
couragement, and acceptance by the therapist form the basis of this
therapeutic alliance (Hubble, Duncan, & Miller, 1999). The art therapist
in this study fits into this description.

Although there are studies of art therapy with pregnant women, we
could not find another well-structured study that specifically targeted
FOC except the study by Wahlbeck et al. (2017). Unlike the case in our
study, they recruited women with severe FOC for five sessions of art
therapy. The only technique they used was drawing. They also struc-
tured every session on a topic relevant to FOC. The vaginal birth rate
(15 out of 19 women) in their study was similar to ours. So, it may be
stated that even though they had one fewer session than our study and
did not use as many art therapy techniques as ours, their outcomes were
similar. In a future study, our art therapy structure with various tech-
niques may be compared to a control group where drawing is the only
technique used.

Music was commonly used in previous studies and chosen to relax
women during the sessions and encourage them to express themselves
more freely in a safe and relaxed environment. It was observed that
starting the sessions with music helped the women to get involved in
their artwork easily. However, we cannot specify if music was the
comforting element as we had music in all six sessions. Therefore, to
understand the effects of music another study may form an art therapy
group for FOC without music as a comparison group.

Image 3. Drawing from the second week.

Image 4. Puppet making session on the 4th week.

C. Sezen and B.Ö. Ünsalver The Arts in Psychotherapy 64 (2019) 9–19

16

We did not find another study where puppet-making was used for
FOC. The puppet-making session was highly appreciated by the women.
Most of the women had fears concerning the health of their baby and
fears of harming the baby during delivery. The puppets that were made
by the women might have had a resemblance to the baby that was in a
way made by the pregnant women via nurturing and carrying the baby
in the womb starting from conception till delivery. So, in a way, they
met their possible “product,” which made them feel more competent as
the future mother of the real baby. In addition to this, it might also have
been easier to project fears and fantasies into a puppet baby than an
abstract mental representation, which must have decreased the anxiety
of uncertainty. Puppets may be similar to the transitional objects
(Trimingham, 2010) defined by Winnicott (1953), where puppets help
women form a preliminary mental representation of the baby. We
suggest puppet-making could be a useful practice in art therapy sessions
while working with pregnant women.

The study by Demecs et al. (2011) used the methods of dancing and
weaving (as a project for the baby). We did not include dancing because
Turkish women are usually ashamed to dance in front of strangers or in
unfamiliar places. Knitting or crocheting things for the baby in preg-
nancy are ordinary activities performed by Turkish women and their
relatives. So we did not find it useful to include in our therapy.

We chose group therapy to be able to reach more women. According
to Spiegel (1994), group therapy has three advantages. Firstly, the
group environment provides its members with social support. Accord-
ingly, in a meta-analysis of 59 studies on postnatal depression, it was
concluded that support groups and having someone to talk to were the
most effective treatment approaches (Dennis & Chung-Lee, 2006).
Secondly, the members have an environment outside of their families
where they can objectively share their concerns. Finally, the group
system is low cost, and time is used more efficiently. Art therapy,
contributing to group cohesion, enables a person to feel less anxiety in
the protected structure of a group (Demecs et al., 2011; Shin & Kim,
2011). In our communications with the art therapy group, nearly all
women said they were at first reluctant to start therapy but admitted
that they felt relieved after hearing similar stories from other women
which made them feel supported. The group members became a part of
each other’s support system. The pregnant women in the art therapy
group exchanged their phone numbers and formed a group in an in-
stant-messaging application where they shared their thoughts and
feelings after the therapy sessions were over. They asked for help from
each other on issues such as breastfeeding or other mutual problems of
taking care of their babies through this messaging application. This was
not something the therapist suggested. It was their decision. This may
indicate that these women who were strangers before the therapies felt
the warmth and protective environment of the group and wanted to
extend this relationship to their everyday lives. So, it may be stated that
the group therapy approach reached its goal of being a safe and pro-
tective social support system.

There was no improvement in the psychoeducation group which
contradicts the results reported in the literature (Fenwick et al., 2015;
Rouhe et al., 2009, 2015; Toohill et al., 2014). The psychoeducation
groups in Rouhe et al.’s (2009) study consisted of six pregnant women
at most. Our control group included 15 women. This relatively high
number in the control group might have decreased the efficacy of the
treatment. Group psychoeducation might be more efficient with fewer
group members. Psychoeducation might have been experienced like a
formal education group that did not focus on the personal concerns of
each woman, and the participants might have felt like students. In
Turkey, students are not interactive participants of classes, but they are
generally passive and obedient takers. On the contrary, art therapy
required the women to be interactive. The art therapist engaged with
each pregnant woman when she instructed, listened and supported the
production of artwork. This might have increased the well-being of the
women. We suggest that art therapy could be helpful for cultures where
verbalizing feelings and thoughts is difficult.

Hypnobirthing is a popular technique for supporting natural de-
livery (Mongan, 2005), but it is rarely used in Turkey due to the lack of
educated staff trained on this technique. Hypnobirthing does not focus
on the personal concerns of the individual pregnant women but on
relaxation exercises and education of women regarding the process of
delivery in similarity to the psychoeducation group. Therefore, art
therapy may seem superior concerning its focus on the psyche of the
woman in various aspects.

In line with the available literature, as the level of FOC measured by
W-DEQ increased, so did the symptoms of anxiety and depression in
both groups (Erkaya, Karabulutlu, & Çalık, 2017; Størksen et al., 2013).
We used BDI and BAI to check for depressive and anxiety symptoms,
and the BDI and BAI scores were above their cut-off points before
starting the treatment in both groups. These women did not have a
prior psychiatric disorder. Therefore, we attributed the increased BDI
and BAI scores to FOC. The BDI score measurements began to show
significant decreases starting from T2, and the BAI score measurements
were significantly lower at T3 in the art therapy group. So, as the fear of
giving birth decreased, the women’s overall psychophysiological func-
tioning improved, and the vaginal birth rates among the women in-
creased consequently. These findings may suggest two things. Firstly, it
may be stated that clinical FOC is a separate condition from anxiety or
depressive disorders. Therefore, during treatment, specific issues re-
lated to FOC need to be addressed. Secondly, the decrease in WDEQ
scores may predict both the efficacy of treatment and the subsequent
mode of delivery. So, if the WDEQ scores do not decrease considerably
when the treatment is finished, further therapeutic work with the ad-
dition of other techniques may need to be planned, which complies
with the PLISSIT model (Saisto & Halmesmaki, 2003).

Previous research included women with severe FOC (W-DEQ > 66)
(Fenwick et al., 2015; Rouhe et al., 2015; Toohill et al., 2014; Wahlbeck
et al., 2017). However, our study and control groups included women
with moderate levels of FOC. Therefore, our results may not be com-
parable to those in previous research. Moderate levels of FOC may also
be disturbing for the women as reflected in the increased levels of an-
xiety and depressive symptoms in our groups. The importance of
moderate levels of FOC on delivery methods has not been studied ex-
clusively. Moderate FOC may go unnoticed and undealt with. However,
the ten women in the psychoeducation group with moderate FOC had
C-section deliveries, which might suggest a possible impact of moderate
FOC on the delivery method. Our study highlights the need for ques-
tioning FOC in every pregnant woman and targeting not only those with
severe FOC but also those with moderate FOC as well.

This study had some limitations. The research was based on one art
therapy and one control group with a sample from only one hospital.
There was only one therapist conducting the therapy sessions. This
might have caused a positive bias toward art therapy because art
therapy requires the therapist to interact with the participants in an in-
depth manner. This could have created a better therapeutic alliance
between the therapist and the participants, and the therapist might
have subconsciously favored those in the art therapy group over the
psychoeducation group. The art therapy and control groups were lim-
ited to 15 women each. Although our sample was small, it might be a
good representation of Turkish pregnant women because the Hospital
where the study took place is a venerable and well-known hospital
among Turkish people that specializes in obstetrics and gynecology care
for women from low- and middle-income backgrounds in a central area
of Istanbul. The research included only pregnant women in their final
trimester. Fear of giving birth is not confined to the final trimester, and
some women may avoid getting pregnant due to FOC. Therefore, the
efficacy of art therapy needs to be studied in different trimesters and
before pregnancy as well. The prevalence of domestic violence in
Turkey is high (57.2%) (Özcan, Günaydın, & Çitli, 2016). Domestic
violence in pregnancy was reported to be 39.8% in a Central-Anatolian
city of Turkey (Alan, Koc, Taskin, Eroglu, & Terzioglu, 2016). Domestic
violence in pregnancy may increase or cause FOC (Hossieni, Toohill,

C. Sezen and B.Ö. Ünsalver The Arts in Psychotherapy 64 (2019) 9–19

17

Akaberi, & HashemiAsl, 2017). We asked the participants about the
occurrence of any new adverse events in their lives at T2 and T3 to
exclude any factors that may interfere with their psychological well-
being. No adverse events were reported. However, domestic violence
was not questioned directly. Women may be ashamed or afraid of
talking about their domestic violence experience, or they might have
normalized it. Occurrence of domestic violence needs to be addressed in
pregnant women with FOC.

Conclusion and recommendations

To conclude, our findings suggest that art therapy is an efficient
method for reducing FOC and levels of anxiety and depressive symp-
toms in pregnant women in their final trimester. This art therapy pro-
gram enabled these shifts in behavior by helping the women face and
express their fears through their artwork (drawing) and then gain
control over their fears (mandala-making, puppet-making, taking pho-
tographs and collage-making) within a secure base and an on-going
social support system provided by the group structure. Art therapy can
be used to change perceptions regarding delivery. Art therapy may be
employed as a method of relaxation, relief and encouragement through
self-expression for pregnant women in preparation for childbirth.
Personalized treatment that focuses on a pregnant woman’s individual
needs might be more productive. However, group therapy may be more
cost-effective for larger groups, especially in developing countries or for
women from low-income backgrounds. We suggest that pregnant
women receive psychological support in the process of preparation for
delivery. A birth psychologist specializes in issues regarding birth
psychology, birth physiology and interpersonal relationships of preg-
nant women and offers psychotherapeutic approaches to problems that
arise in pregnancy (Karabekir, 2016). The effectiveness of the birth
psychologist may increase in the course of overcoming FOC, which
impedes the rates of vaginal births.

Funding

This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.

Declarations

Part of this work has been presented as a poster presentation at the
25th European Congress of Psychiatry and it’s abstract has been pub-
lished in European Psychiatry 2017, vol: 41, p909. https://doi.org/10.
1016/j.eurpsy.2017.01.1868.

Acknowledgments

The presented paper includes some of the findings from the Master’s
Thesis of the second author.

The second author designed the structure of art therapy sessions and
also conducted the group therapies.

The first author planned the methods of the study and interpreted
the findings of the study. The first author wrote this manuscript.

The nurses in the hospital helped with the referral of the pregnant
women, and they also provided a comfortable space for group thera-
pies.

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Fear of Childbirth in Pregnant Women in the United States

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DOI: 10.15761/JPR.1000135

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Research Article

Journal of Pregnancy and Reproduction

J Pregnancy Reprod , 2018 doi: 10.15761/JPR.1000135 Volume 2(2): 1-5

ISSN: 2515-1665

Fear of childbirth in pregnant women in the United States
Runnals JJ1 and Vrana SR2*
1Department of Veterans Affairs Medical Center Durham, North Carolina, USA
2Department of Psychology, Virginia Commonwealth University Richmond, Virginia, USA

Abstract
Objective: The purpose of this investigation was to assess the incidence of serious childbearing fear in a sample of American women, and to explore associations
between women’s experiences and fear of childbirth.

Methods: Ninety women 25 weeks of gestation and later who participated in a prospective longitudinal study were administered questionnaires during pregnancy
that included background factors (marital status, education, birth history), fear of childbirth, and current levels of depression and posttraumatic stress disorder
symptomology.

Results: The incidence of serious fear of childbirth (7.7%) was slightly lower than but consistent with studies of Northern European women. When considered
separately, 11.6% of women in the care of an obstetrician and 4% of women in the care of a midwife exhibited serious levels of fear. Greater fear of childbirth was seen
in women experiencing sexual assault in both childhood and adulthood but not in women endorsing childhood sexual assault alone. Fear was higher among women
with a current diagnosis of depression or co-morbid depression and Posttraumatic Stress Disorder.

Conclusion: These results underscore the importance of identifying and treating depression in pregnant women.

Correspondence to: Scott R Vrana, PhD, Department of Psychology Virginia
Commonwealth University Richmond, Virginia, 23284-2018, USA, Phone: 01-
804-828-1242, E-mail: [email protected]

Key words: depression, fear of childbirth, United States

Received: April 13, 2018; Accepted: April 19, 2018; Published: May 02, 2018

Introduction
Studies of Northern European women indicate that serious levels

of childbearing fear occur in 7.3% to 15.6% of pregnant women [1-
7]. Excessive childbearing fear is a concern given its relationship with
increased healthcare utilization [8,9], complicated birth [10, 11], and
increased risk for instrument-assisted or operative deliveries [1,5, 12].
Fear of childbirth is a topic that has received little objective investigation
in American women despite its influence on maternal request cesarean
sections [12-15], which have increased in the U.S., the controversy
surrounding these requests [16-17], and concern about the lack of
information suggesting how providers attend to serious childbirth fear.

More fearful women have excessive concerns regarding child
malformation, physical damage to the fetus, painful injections,
injury to the fetus or themselves during delivery, and fear of pain or
of becoming hysterical during delivery [18-20]. Understanding what
concerns women with serious childbirth fear does not necessarily
illuminate why some women are more afraid than others. Explanations
for severe fear have included exposure to traumatic stories of childbirth
or actual experience of traumatic birth [21], fear of the unknown
among first-time mothers [22-24], and history of sexual abuse [1]. It is
unknown whether similar factors are associated with fear in American
women and what role the presence of trauma and depressionrelated
symptomology may play in fear of childbirth.

Given the paucity of information regarding childbearing fear
in women from the U.S. this study was undertaken to investigate
childbearing fear in American women. It was expected that women
with childhood sexual assault would be more fearful of birth and it was
hypothesized that women with a history of miscarriage, difficult birth,
and current trauma or depression diagnosis would have higher levels
of fear.

Materials and Methods
Participants and procedures

After obtaining approval from the Virginia Commonwealth
University Institutional Review Board, data were collected in a number
of sites in the mid-Atlantic by approaching women attending prenatal
appointments in participating clinics, and by placing advertisements
in clinics and local businesses. Women were eligible to participate if
they were 18 or older, past their 24th week of gestation and provided
informed consent. Women who met criteria were given a packet of self-
administered questionnaires and a pre-addressed, stamped envelope to
return measures.

Measures

The packet included questions regarding background information
(e.g., age, race, income and employment status, marital status, number
of children, and obstetrical variables such as current week of gestation,
type of prenatal care provider, past birth experience including type of
prior delivery, history of miscarriage, history of stillbirth, whether they
had asked their provider for surgical delivery based on childbearing
fear, and a rating of their preference for c-section over vaginal delivery)
as well as the following measures: 1) The Wijma Delivery Expectancy
Questionnaire ([25]; WDEQ), a 33-item measure of childbearing fear
with scores ranging from 0-165 and the consensus choice in the field

Runnals JJ (2018) Fear of childbirth in pregnant women in the United States

Volume 2(2): 2-5J Pregnancy Reprod , 2018 doi: 10.15761/JPR.1000135

for measuring this construct [26]. Researchers suggest a cut-off score
of ≥ 85 as indicating serious fear of childbirth [5-7]. 2) The Edinburg
Postnatal Depression Scale ([27]; EPDS), a ten-item screening of
postnatal depression symptomology that has been validated for use
during pregnancy [28]. Based upon prior work [27, 29, 30] a cut-off
score of 12 was used to indicate likely diagnostic levels of depression.
3) The Posttraumatic Diagnostic Scale ([31]; PDS) a 57-item measure
of recent Posttraumatic Stress Disorder (PTSD) symptomology and
assessment of all DSM-IV criteria for PTSD. The PDS has been used
in prior studies of pregnant and postpartum women [32, 33] and was
suggested as an appropriate self-report measure by a consortium of
researchers of pre and postpartum trauma [34].

For this study, early sexual assault (ESA) refers to positive
endorsement of the PDS item assessing sexual contact prior to age
18 with someone five or more years older. Repeated sexual assault
(RSA) refers to women’s endorsement of early sexual assault and
sexual assault in adulthood. Womenwere considered to have a trauma
diagnosis if they met criteria for PTSD or if they were subthreshold
(i.e. endorsed criterion A1 and A2 for diagnosis of PTSD but did not
fully meet B, C, or D criteria or alternatively did not meet criterion
A2 but did endorse diagnostic levels of trauma symptomology). Prior
difficult birth was assessed by endorsement of the following: “difficult
or upsetting childbirth (for example, an emergency c-section or forceps
delivery, stillborn child, extremely painful labor, or a lot of tearing
during delivery)”.

Analyses

The results are reported as mean and standard deviation and when
appropriate as percentages with 90% confidence intervals. Group
comparisons of continuous data were made with independent t-tests
or Analysis of Variance (ANOVA) and categorical data with chi-square
tests for independence. A significance level of p <.05 was considered
statistically relevant.

Results
Sample description

One-hundred and four women agreed to enroll in the study.
Ninety women returned the pre-delivery packet of questionnaires,
an 84% response rate, which is consistent with [5] or exceeds [1, 2, 6]
response rates in similar studies. Demographic characteristics of the 90
participants are shown in Table 1. The sample is not representative of
all childbearing women in the U.S. as it consisted primarily of working
and college-educated, married, Caucasian women. In addition, half
of the participants were in the care of a midwife, which significantly
exceeds the typical rate of 7% women in midwifery care in the United
States. Seventeen women (18.8%) reported sexual assault during
childhood on the PDS; adult or childhood sexual assault was endorsed
by 28% of participants. Both childhood and adult sexual assault were
reported by 10% of women (n=9). Four or 4.4% of participants were
assigned a diagnosis of PTSD based on the PDS, which is lower than
population estimates of 10-12% [35-37]. An additional 14% met
criteria for subthreshold PTSD. Twenty-four percent of participants
were assigned a diagnosis of depression based on exceeding the cut-off
score of 12 on the EPDS.

Incidence of childbearing fear

Internal reliability of the WDEQ was high (Cronbach’s α =.93) and
consistent with prior work [1, 5]. Similar to prior studies, mean fear
for the entire sample was 54.1 (SD=21.2). The incidence of serious fear

of childbirth, defined as WDEQ ≥85, was 7.7% (90% CI [3.1%, 12.3%]
; n=7), which is generally lower than rates for non-U.S. women. Of
women in the care of an obstetrician 11.6% (90% CI [5.6%, 16.4%];
n=5) showed serious childbearing fear. This is more commensurate
with rates of fear in non-U.S. women than the 4.0% (90% CI [0.6%,
7.4%]; n=2) rate for women in care of a midwife. Fear among obstetrical
patients was greater (X=61.9 SD=21.0) than among midwifery patients
(X=47.0, SD= 18.9), t(88)=3.54, p<.001. Four percent of women (n=4)
indicated having already requested a c-section for fear; however only
two of these women had fear levels on the WDEQ ≥85, suggesting that
the weight women give to certain aspects of fear, rather than only the
absolute amount of fear, may play a role in some maternal requests for
cesarean section for fear. Thus a WDEQ score of ≥85 may not capture
all women who would like to avoid vaginal delivery due to fearfulness.
There was a moderate correlation between level of childbearing fear
and increasing preference for surgical over vaginal delivery (r=.31,
N=90, p<.001).

Factors associated with childbearing fear

Table 2 shows the results from group comparisons of childbearing
fear in women with and without prior birth experience (women with
history of birth trauma were excluded from this comparison), history
of miscarriage, prior difficult birth (women with no birth history were
excluded from this comparison), and past sexual assault. Contrary
to a prior finding [14] but consistent with more recent work [4, 38]
women with and without history of miscarriage showed similar levels
of childbearing fear. As expected, mean fear scores were higher in
women with prior difficult birth and higher among women reporting
early sexual assault; however, these differences did not reach statistical
significance. For women who endorsed repeated sexual assault (RSA)
their level of childbearing fear was significantly greater than women
not reporting RSA. Thirty-three percent of women with repeated
sexual assault were high in fear compared to 4.9% of women without
history of repeated sexual assault, a relative risk increase of 73%.The
results partially support the hypothesis that women with PTSD would
have greater levels of childbearing fear given posttraumatic symptoms
such as hypervigilance for danger: Fear levels were moderately
correlated with trauma (r=.32, p<.01) and depression (r=.50, p<.01)
symptomology. As shown in Table 3, in a one-way ANOVA using
Tukey’s HSD for post-hoc analyses, women with a trauma diagnosis

Characteristic (n=90) M (SD) or %
Age (in years) 30.47 (4.58)
Education (in years) 15.73 (2.30)
Income Level $46,577 (14,475)
% African-American 10%
% married 85.6%
Employed F/PT 62.2%
History of Psychiatric Diagnosis 63.3%
Any Sexual Trauma 27.8%
Early Sexual Trauma 10%
OB Provider 47.8%
Midwife Provider 52.2%
Prior Birth Experience 43.3%
Endorsement of ≥ Criterion A Event 71%
PTSD Diagnostic Scale 4.17 (6.89)
Depression Symptoms on EPDS 8.01 (4.96)
Fear of L&D on WDEQ 54.12 (21.20)

Table 1. Participant characteristics.

Note. EPDS=Edinburgh Postnatal Depression Scale; WDEQ-A=Wijma Delivery
Expectancy Questionnaire.

Runnals JJ (2018) Fear of childbirth in pregnant women in the United States

Volume 2(2): 3-5J Pregnancy Reprod , 2018 doi: 10.15761/JPR.1000135

were higher in fear than women with no diagnosis; however, it was only
among women with co-morbid depression and trauma diagnosis, or
depression alone, that the difference in level of fear between those with
and without diagnoses reached statistical significance. Of the seven
women in this study with serious childbirth fear, five met criteria for a
likely diagnosis of depression; 22.7% of women with depression were
also seriously fearful of childbirth compared to 2.9% of women without
depression, a relative risk increase of 82%.

Given that women who experience sexual contact or assault during
childhood and who subsequently experience sexual assault during
adulthood are particularly susceptible to comorbid psychological
disorders [39-43], a chi-square test was conducted looking at the
association between repeated sexual assault and diagnostic status
(no diagnosis, trauma only, depression only, or both). This test was
marginally significant [χ2(3, N=90) =6.32, p=.09, phi=.27]. Both RSA
(yes or no) and level of depressive symptomology were then entered into
a regression analysis to determine whether current levels of depression
would better account for the variance in childbearing fear than repeated
sexual assault and whether RSA is a predictor of childbearing fear only
at higher levels of depression. Repeated sexual assault was entered
in step one and accounted for 5.3% of the variance in childbearing
fear. Depression symptoms were entered in step two explaining an
additional 22.7% of the variance in childbearing fear. The interaction
of depression symptoms and repeat sexual assault was entered in step
three and while the full model was significant, F(3,85)=11.26, p<.01,
accounting for 28.4% of the variance in childbearing fear, the only
significant predictor in the final step was depression. In this sample
78% of women with RSA and depression diagnosis (n=7) were high in
childbearing fear whereas no women with RSA who lacked depression
diagnosis (n=2) were high in fear. These results suggest that the
relationship between repeated sexual assault and fear of childbirth is
mediated by depression.

Discussion
The main goals of this study were to assess levels of serious

childbirth fear and factors associated with fear in a sample of pregnant
American women. Incidence of serious childbirth fear was 7.7%. The
incidence of fear was higher (11.6%) when only considering women in
the care of an obstetrician, though these women may have additional
reasons for increased fear (e.g. high-risk pregnancies) that were not
assessed in this investigation. However, the level of fear in women

in care of an obstetrician is similar to fear levels in non-U.S. women
and suggests consistency of fear levels among pregnant women in
developed countries. Serious fear was not exclusive to obstetrical care
and it is notable that there were women with high levels of fear who
chose the care of a midwife, indicating that management of high levels
of childbirth fear is a salient issue for all prenatal care providers.Greater
fear of childbirth was associated with increased preference for maternal
request c-section, and four women indicated having already requested
an elective c-section for fear. While this is a seemingly small number of
women, it is 4.4% of the sample, and if applied to the 4 million women
delivering annually in the U.S. [44] these findings suggest 176,000
women may be distressed enough to prefer surgery over vaginal
delivery and to make this request of their providers. In addition to
the increased expense for surgical delivery [45] there are ethical and
medical concerns regarding maternal request c-section (e.g. increased
mortality and complications in future pregnancies [46-48] or increased
risk of respiratory difficulties in newborns [17]). There is also variability
in terms of women’s access to this option and physicians’ willingness
to provide elective c-section [49, 15] as well as limited evidence that
maternal request c-section prevents negative birth experience. [50, 51]

While fear was higher among women without birth experience and
women with prior difficult birth, these levels were still within the typical
range of childbirth fear. Only among women with history of repeated
sexual victimization and those struggling with depression and trauma
symptomology (not mutually exclusive categories) did fear levels begin
to show significant elevations. There is prior evidence for a relationship
between anxiety and depression and fear of childbirth [8, 26], and
sexual assault and fear of childbirth [1]; the current work suggests that
depression mediates the relationship between these negative personal
experiences and childbearing fear. Negative expectations and fear
regarding childbirth may be rooted in belief systems associated with
depression (e.g. global and stable negative beliefs regarding the world,
self, and others) though this speculation requires additional study. The
implication is that women with serious fear are not simply exaggerating
typical concerns regarding childbirth, and that they are unlikely to be
re-assured by minimizing these concerns (e.g. by presenting evidence
regarding the very small number of catastrophic outcomes). Rather
these women likely have substantive negative expectations that have
been reinforced by difficult life experiences that reach far beyond
the infrequent occurrence of birth. These results underscore the
importance of identifying and treating depression in pregnant women
and point to potential additional options for obstetrical providers
attending patients with serious fear (i.e. psychotherapy in addition to
or in place of either elective surgery or no treatment). On a practical
level, this study shows that the 10-item EPDS can successfully identify
women at an 82% increased risk for serious childbirth fear who could
potentially benefit from psychological intervention and possibly reduce
costly healthcare utilization.

One of the primary contributions of this work is that the incidence
of childbearing fear in American women is similar to the incidence of

Variable n=yes M (SD) n=no M (SD) t-score p ES
Prior Birth 27 51.26 (22.79) 51 54.94 (20.47) t(76)= .727 .47 .0070

Difficult Birth 12 57.08 (21.74) 27 51.26 (21.22) t(37)=-.747 .46 .0148
ESA 17 58.77 (27.32) 73 53.04 (19.59) t(88)=-.1.00 .32 .0112
RSA 9 68.33 (24.82) 81 52.54 (20.32) t(88)==2.16 .03 .0504

Miscarriage 23 54.52 (24.19) 67 53.98 (20.27) t(88)=-.104 .92 .0001

Note. ESA=early sexual assault; RSA=repeated sexual assault; ES=effect size.

Table 2. Independent t-tests Comparing Childbearing Fear on WDEQ Between Women with a History of Miscarriage, Prior Difficult Birth, and Sexual Assault.

Group n M SD
No Diagnosis 59 48.32* † 20.06

Trauma Diagnosis Only 8 53.88 16.13
Depression Only 13 68.08* 19.23

Trauma Diagnosis &
Depression 9 72.89† 16.93

Table 3. Childbearing Fear Among Women with Depression, Trauma Diagnosis, Both, or
No Diagnosis.

Note. * and † indicate significant differences between groups, p ≤ .05.

Runnals JJ (2018) Fear of childbirth in pregnant women in the United States

Volume 2(2): 4-5J Pregnancy Reprod , 2018 doi: 10.15761/JPR.1000135

serious fear found in non-U.S. women, and suggests consistency in fear
rates across women from various developed countries. While this study
provides greater understanding of the relationship of psychopathology
to childbearing fear in primarily Caucasian, college-educated women,
its generalizability may be limited, and it is unknown whether this
relationship would differ for women of other ethnicities, economic
levels, or age (e.g. in pregnant adolescents). Investigations are also
needed to determine the effect that greater levels of childbearing
fear play in the provision of care for pregnant women in the U.S.
(i.e. increased healthcare utilization, increased provider burden), as
well as to better understand the relationship between excessive fear,
depression, and maternal request c-section.

Contributions
Jennifer Runnals: topic development, data collection, analysis,

manuscript preparation, writing. Scott Vrana: topic development,
analysis, writing, editorial assistance.

Competing interests
The authors have no competing interests to report.

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Contents lists available at ScienceDirect

Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

From experiences to expectations: A quantitative study on the fear of
childbirth among multigravida women

Oznur Korukcua,⁎, Okan Bulutb, Kamile Kukulua

a Akdeniz University Faculty of Nursing, Department of Obstetrics and Gynecology, 07058 Antalya, Turkey
bUniversity of Alberta, Department of Educational Psychology, 11210 87 Ave NW, Edmonton, AB T6G 2G5, Canada

A R T I C L E I N F O

Keywords:
Childbirth fear
Experiences
Midwifery
Nursing
Parturition

A B S T R A C T

There is a strong relationship between women’s previous birth experiences and their predetermined expecta-
tions. Childbirth expectations play an important role in the women’s response to the birthing experience and
postpartum period. The negative emotions and expectations, such as fear of childbirth, may result in negative
experiences in subsequent childbirths. The aim of this study is to examine the relationship between previous
birth experiences and the fear of childbirth in current pregnancy. A sample of 309 healthy women with normal
pregnancies was recruited for this study. A chi-square test of independence and a multinomial logistic regression
were used to explain the association between previous birth experiences and the fear of childbirth in current
pregnancy. The level of childbirth fear that pregnant women feel appears to differ based upon their previous
pregnancy experiences. Pregnant women who describe their previous births as happy and proud tend to ex-
perience a moderate level of childbirth fear about their current pregnancies, whereas pregnant women who
remember their previous births as either fearful or painful have lower levels of childbirth fear. The level of
childbirth fear tends to decrease as pregnant women have more children. Gestational week does not seem to be
influential on the level of childbirth fear. According to the findings of this study, counterintuitively there is a
negative relationship between the previous birth experience and childbirth fear. The level of childbirth fear is
lower for pregnant women who remember their previous births as a negative experience compared to those who
remember their previous births positively.

Introduction

Literature review

Parturition is the great transitional event in the reproductive cycle
of a woman. Apart from the natural causes of apprehension and doubt
in the ordinary human being, a woman who is about to have a baby is
subject to fear-producing factors peculiar to the stage of pregnancy and
childbirth (Dick-Read, 2009). The fear of childbirth, which is also
known as tokophobia in the literature (Hofberg & Brockington, 2000),
has been described as a form of anxiety caused by the forthcoming birth
(Lukasse et al., 2014). From a very early age, girls become aware of the
accepted teaching that having a baby is a dangerous and painful pro-
cedure (Rouhe, Salmela-Aro, Halmesmäki, & Saisto, 2009).

There is a link between women’s upcoming birth experiences and
their predetermined expectations (Hauck, Fenwick, Downie, & Butt,
2007). Parity is one of the most important factors that can influence the
contents of fear in childbirth process (Størksen, Garthus-Niegel,

Vangen, & Eberhard-Gran, 2013). Worries about the health of the baby,
fear of losing the baby, fear of intolerable pain during labour, and fear
of prolonged labour are the most common reasons of fear among pri-
migravida women (Kızılırmak & Başer, 2016; Smarandache, Kim, Bohr,
& Tamim, 2016). In contrast, childbirth fear among multiparous women
is often based on their previous birth experiences, such as the fear of
obstetric injuries during labour, loss of control, insufficient support, and
an inability to cope with labour (Eriksson, Jansson, & Hamberg, 2006;
Hauck et al., 2007; Størksen et al., 2013). On the other hand, owning
and believing in birth as a natural event, satisfaction with the birth
process and outcome, and involvement and participation in the birthing
experience are the important effects of positive birth attitudes for both
primigravida and multigravida women (Hauck et al., 2007). Sluijs,
Cleiren, Scherjon, and Wijma (2015) stated that women with childbirth
fear in pre-partum tend to have higher levels of childbirth fear in post-
partum, regardless of what obstetric complications they had to cope
with. Women who suffer from severe childbirth fear typically need
professional support for a healthy transition to motherhood.

https://doi.org/10.1016/j.apnu.2018.11.002
Received 3 April 2018; Received in revised form 14 July 2018; Accepted 9 November 2018

⁎ Corresponding author.
E-mail address: [email protected] (O. Korukcu).

Archives of Psychiatric Nursing 33 (2019) 248–253

0883-9417/ © 2018 Elsevier Inc. All rights reserved.

T

There is a strong relationship between the fear of childbirth and
negative birth outcomes. They both affect maternal psychological
wellbeing, adaptation to motherhood, lower self-rated health, persis-
tent memory of pain, and the quality of the mother’s relationship with
the infant (Pazzagli et al., 2015; Smarandache et al., 2016). Størksen
et al. (2013) found that the association between a previous negative
birth experience and childbirth fear was greater than the association
between previous obstetric complications and childbirth fear. Ac-
cording to the results of their study, women who had experienced ob-
stetric complications were more likely to have had a negative overall
birth experience and to develop a fear of childbirth; however, the ma-
jority of women who experienced obstetric complications did not have
a negative overall birth experience and did not develop a fear of
childbirth (Størksen et al., 2013). A woman’s birth experience can in-
fluence her physical and mental well-being long after the birth of her
child (Niebler, Documét, Chaves-Gnecco, & Guadamuz, 2016). Fur-
thermore, a negative birth experience has been shown to be associated
with prolonged labour and elective cesarean section (Saisto &
Halmesmäki, 2003; Smarandache et al., 2016).

Childbirth is one of the most important developmental transitions in
a woman’s life (Korukcu, Bulut, & Kukulu, 2016). To date, there has
been limited research about the effects of previous childbirth experi-
ences on Turkish women’s fear of childbirth during their current preg-
nancies. Therefore, this study aims to examine the effects of previous
birth experience(s) of Turkish women on the fear of childbirth in cur-
rent pregnancy. The findings of this study will provide psychosomatic
evidence about the effects of previous birth experiences on the fear of
childbirth in current pregnancy and help pregnant women understand
the causes of their childbirth fear during their transition to motherhood
process. In addition, the findings of this study will be helpful for
healthcare practitioners in promoting positive attitudes towards child-
birth among pregnant women.

Theoretical framework

The Mercer’s Maternal Role Attainment Theory, which is a client-
oriented theory that adapts to each mothers’ individual needs, was used
in the theoretical framework of this study to determine the effect of
previous birth experiences on the level of childbirth fear in current
pregnancy. Mercer (2004) states that the transition-to-motherhood
process emerges with each newborn child. This view is the starting
point for planning the current research.

Reva Rubin first developed the theory on maternal identity and role
attainment in 1967, which was taken and expanded upon by Mercer
(Mercer, 2004; Noseff, 2014). Following that theory, the midwife’s or
nurse’s role is seen as helping women adapt to the “maternal role”
(Hung, Yu, Chang, & Stocker, 2011). The philosophy of this perspective
locates the pregnant woman at the centre of the process and places
midwives or nurses in an ideal position to draw upon the concept of
maternal representations in order to support not only a woman’s phy-
sical transition to motherhood, but also her psychological transition to
motherhood (Meighan, 2013; Mercer, 2004). In the light of this theory,
researchers wanted to pay attention to the psychosocial health of
multiparous women in transition to motherhood process. Every birth
journey is unique and maternal birth experiences, expectations, and
perceptions may affect a woman’s subsequent pregnancies (Korukcu
et al., 2016). Therefore, this study will seek for evidence of the influ-
ence of past experience of multiparous women on future pregnancies
and level of fear of childbirth.

Methods

Study population

A sample of 309 healthy women with normal pregnancies was re-
cruited in this study. Data were collected from pregnant women

through a paper-and-pencil survey and face-to-face interviews when
they were attending the routine scan at the Antalya Training and
Research Hospital between June and December 2015. The following
selection criteria were used to recruit the participants of this study: (1)
being a multigravida; (2) visiting to the Antalya Training and Research
Hospital for routine controls; (3) gestational ages of between 28 and
40weeks with a healthy baby; (4) being 18 years or older; (5) having no
psychiatric or chronic disease; and (6) reading, writing, speaking, and
understanding Turkish proficiently.

Instruments

The fear of childbirth during pregnancy was measured by the Wijma
Delivery Expectancy/Experience Questionnaire – version A (WDEQ-A).
The W-DEQ-A is a 33-item questionnaire, with each item being scored
as ‘not at all’ (0) to ‘extremely’ (5) (Wijma, Wijma, & Zar, 1998). In
addition to the items in the W-DEQ-A, each participant responded to a
set of demographic questions about age, occupation, socioeconomic
status, education, and obstetric history and parity. Coefficient alpha
reliability coefficient of the W-DEQ-A was 0.88 for primigravida women
and 0.90 for multiparous pregnant women in a validity and reliability
study conducted by Korukcu, Kukulu, and Firat (2012). In this study,
the reliability of the WDEQ-A was 0.84, suggesting a high level of re-
liability for the instrument (Korukcu, Fırat, & Kukulu, 2010).

The total scores in the WDEQ-A can be computed by summing up
individual item scores for each participant. This process results in a
minimum score of zero and a maximum score of 165. A higher score
indicates a more intense fear of childbirth. To place all of the items in
the same direction, the positively worded items (item 2, 3, 6, 7, 8, 11,
12, 15, 19, 20, 24, 25, 27, 31) need to be reversed coded before the
calculation of the participating women’s total score in the WDEQ-A
(Wijma et al., 1998).

Ethical considerations

A written permission letter from the Head Physician’s Office in the
Antalya Training and Research Hospital was obtained for the study. The
Antalya Training and Research Hospital Scientific Research Assessment
Board reviewed the proposed study and provided ethics approval for
the implementation of the study. The objective of the study was ex-
plained to the pregnant women who were eligible to participate in the
study, and the written consents were obtained from those who accepted
to take part in the study.

Data analysis

The analysis of the data began with the calculation of the partici-
pants’ scores in the WDEQ-A. Fig. 1 shows that the WDEQ-A scores
obtained from the participants of this study were normally distributed
(M=68.26, SD=19.24). Next, the W-DEQ-A total scores were used to
categorize pregnant women based on the level of fear that they feel
about their current pregnancy as follows: zero to 60 points indicating
low fear of childbirth, 61 points to 84 points indicating moderate fear of
childbirth, and 85 points or above indicating severe fear of childbirth
(Korukcu et al., 2010; Nieminen et al., 2017). Table 1 shows a demo-
graphic summary of the participants in the sample of this study by their
level of fear based on the WDEQ-A scores.

The categorization of the WDEQ-A total scores as low, moderate,
and high was necessary because (1) the categorical scale of WDEQ-A
reflects more meaningful differences between pregnant women than the
continuous scores from WDEQ-A; (2) regression-based analyses based
on continuous WDEQ-A scores were not feasible due to the lack of
empirical evidence suggesting a linear relationship between the fear of
childbirth and how previous pregnancy experiences are remembered
(i.e., proudly, happily, in pain, or in fear); and (3) categorical data
analysis was a more suitable option for identifying the relationship

O. Korukcu et al. Archives of Psychiatric Nursing 33 (2019) 248–253

249

between childbirth fear and previous experiences for pregnant women
with severe childbirth fear as the size of this group was quite small
compared to the rest of the sample (see Fig. 1).

To examine the relationship between the pregnant women’s level of
fear (i.e., low, medium, or high) regarding their current pregnancy and
how they remember their previous pregnancy experiences (i.e.,
proudly, happily, in pain, or in fear), two statistical procedures were
implemented. The participating women’s level of fear based on the W-
DEQ-A scores and their responses to the question of how they re-
member their previous childbirth experiences were used as the de-
pendent and independent variables, respectively. First, a chi-square test
of independence was used to examine whether the two categorical
variables are significantly associated with each other. Second, given the
statistically significant association, a multinomial logistic regression
was used to predict the level of fear for current pregnancy (dependent
variable) using the perception of past pregnancy experiences (in-
dependent variable). In the multinomial logistic regression model, the

number of prior pregnancies was included as a covariate to control for
its effects on the level of childbirth fear.

Results

Fig. 2 shows the percentages of the pregnant women by the two
variables used in this study (i.e., the level of childbirth fear and the
recall of previous pregnancies). Most of the participants who remember
their past pregnancy experiences either happily or proudly indicated a
medium level of fear regarding their current pregnancy. Unlike these
participants, the participants who remember their past pregnancy ex-
periences as either fearful or painful mostly indicated either low or
medium levels of fear about their current pregnancy.

Table 1 shows that 30.4% of multiparous pregnant women indicated
low-level childbirth fear, 19.1% of them indicated high-level childbirth
fear; and the majority of the participants (50.5%) indicated moderate-
level childbirth fear. Most pregnant women who have only one child
indicated moderate fear of birth, whereas pregnant women with 2 and
more children indicated low-level birth fear about their current preg-
nancy. This finding suggests that the level of childbirth fear tends to
decrease as pregnant women have more children. Finally, gestational
week does not seem to be influential on the level of fear of childbirth.

To test the strength of the association, a chi-square test of in-
dependence was conducted. The result of the chi-square test showed
that there was a statistically significant association between the level of
fear that pregnant women feel about their current pregnancy and their
past pregnancy experiences, χ2(26)= 21.068, p < .05. This finding
suggests that pregnant women’s level of childbirth fear tends to vary
depending on their past pregnancy experiences. The Spearman corre-
lation between the level of fear about current pregnancy and their past
pregnancy experiences indicated a negative relationship (rs=−0.17,
p < .05). In addition, Cramer’s V, which tests the strength of associa-
tion between categorical or ordinal variables, indicated that the
strength of association between the level of fear for current pregnancy
and feelings about previous pregnancy/birth experiences was moderate
(V= 0.185, p < .002).

Next, a multinomial logistic regression model was used to predict
the effects of previous pregnancy experiences on the level of childbirth
fear for the current pregnancy. The “medium” level fear was selected as
the baseline (i.e., reference) category in the dependent variable. That is,
a positive regression coefficient for previous pregnancy experiences
would suggest that the log odds of being in the low-level fear or high-
level fear categories is higher than the log odds of being in the medium-
level fear category. In addition, the “in pain” category was selected as
the baseline category in the independent variable. That is, the estimated

Fig. 1. Distribution of the total scores in WDEQ-A.

Table 1
Demographic summary of the participants in the study.

Demographic variables Level of fear

Low Medium High

N % N % N %

Age 18–19 0 0 17 65.4 9 34.6
20–24 24 22.4 65 60.8 18 16.8
25–29 31 32.0 50 51.5 16 16.5
30–34 20 44.4 18 40.0 7 15.6
35–39 15 50.0 6 20.0 9 30.0
40–44 4 100 0 0 0 0
45 or older 0 0 0 0 0 0

Education Primary school 41 33.6 57 46.7 24 19.7
Middle school 26 43.3 20 33.3 14 23.4
High school 19 19.4 65 66.3 14 14.3
College degree 8 29.6 13 48.1 6 22.3
Graduate degree 0 0 0 0 0 0
Illiterate 0 0 1 50.0 1 50.0

Number of children 1 51 23.0 129 58.1 42 18.9
2 31 44.3 25 35.7 14 20.0
3 10 71.4 1 7.1 3 21.5
4 1 50.0 1 50.0 0 0
5 1 100 0 0 0 0
6 0 0 0 0 0 0

Duration of pregnancy 30 weeks or less 30 31.6 44 46.3 21 22.1
31–34weeks 12 16.9 42 59.2 17 23.9
35–38weeks 26 44.1 24 40.7 9 15.2
> 38weeks 26 31.0 46 54.8 12 14.2

Total 94 30.4 156 50.5 59 19.1

Fig. 2. Percentages of pregnant women by the level of childbirth fear and how
they remember their previous pregnancy.

O. Korukcu et al. Archives of Psychiatric Nursing 33 (2019) 248–253

250

effects for the other categories (happily, proudly, or in fear) would be
relative to the “in pain” category.

Table 2 shows the results of the multinomial logistic regression
analyses. The results indicated that the log odds of having a “low” level
of fear vs. a “medium” level of fear decrease if the pregnant women’s
previous experiences change from “in pain” to “happily” or “proudly”.
That is, pregnant women who remember their previous pregnancies
positively (i.e., either happily or proudly) are more likely to have the
medium level of birth fear than the low level of birth fear. There was no
significant effect of moving from “in pain” category to “in fear” on the
likelihood of being in the low fear category vs. the medium fear cate-
gory. The results were slightly different for the comparison of “high”
fear against “medium” fear. As pregnant women’s previous pregnancy
experiences change from “in pain” to “happily”, the log odds of having
a “low” level of fear vs. a “medium” level of fear decrease. That is,
pregnant women who describe their previous pregnancy as a happy
experience are more likely to have the medium-level fear than the low-
level fear. Unlike the findings for the low-level fear, changing from “in
pain” to “proudly” in previous pregnancy experiences does not appear
to have a significant impact. Similarly, the “in fear” category was not
statistically influential on the log odds of having a high level of fear vs.
a low level of fear.

Discussion

Previous studies reported that the state of experiencing fear of
childbirth in current pregnancies of multiparous women is related to
what they have experienced before (Sluijs et al., 2015). Severe child-
birth fear can be experienced by pregnant women because of their
previous birth experiences, and these women can encounter birth
trauma in their future pregnancies (Nilsson, Bondas, & Lundgren,
2010). Multiparous pregnant women with negative birth experiences
tend to remember their births as fearful and they express negative
feelings about their previous births (Fenwick, Toohill, Creedy, Smith, &
Gamble, 2015; Nilsson et al., 2010). Negative birth experiences also are
associated with less fulfilling, being less satisfied with birth and re-
porting less emotional wellbeing after birth in future pregnancies
(Turkstra et al., 2017). This notion necessitated the planning of the
current study.

In this study, 30.4% of multiparous pregnancies were in the low
birth fear category, 50.5% of them were in the medium birth fear ca-
tegory, and 19.1% were in the high birth fear category. Furthermore,
most of the pregnant women who had severe birth fear about their
current pregnancy were 18–19 years old. In the literature, it has been
specified that young mother age is an important factor that may lead to
an increase in the level of childbirth fear (Rouhe et al., 2009; Størksen
et al., 2013; Räisänen et al., 2014; Nieminen et al., 2017). Our findings

are aligned with the existing literature about the relationship between
age and the level of birth fear. Being a mother adds a social value to a
woman in the Turkish culture, and birth gives the woman a new
identity and a social status among her family members, relatives,
friends, and the community (Korukcu et al., 2016). The results of the
study can be explained with opinions of Turkish women about child-
birth. Even if mothers had negative birth experiences, they might dis-
regard their bad memories and meet their future pregnancy with hap-
piness and gratefulness. Furthermore, Mercer (2006) stated that the
transition-to-motherhood process emerges with each newborn child.
Mothers’ previous birth experience can increase self-confidence and
ability to overcome a difficult situation, such as the birth (Korukcu
et al., 2016). New roles and responsibilities after childbirth may con-
tribute to the psychological maturation and growth of mothers.

This study also indicated that pregnant women who experienced a
high level of birth fear in their previous pregnancies are more realistic
in their future pregnancies and know what to expect from their births
(Räisänen et al., 2014; Fenwick et al., 2015). Størksen et al. (2013)
argued that pregnant women who remember their previous births as
fearful or painful might struggle with coping with issues in their future
pregnancies. The results of the work done by Fenwick et al. (2015) also
support this claim. Some of the pregnant women who had negative
experiences in their previous births appear to be stronger in their cur-
rent pregnancies and they have a longer-term experience that can allow
them coping with the problems of the pregnancy (Räisänen et al., 2014;
Fenwick et al., 2015). Unlike this finding, this study showed that the
level of childbirth fear experienced by pregnant women who remember
their past births negatively was lower than those who remember their
past births positively.

A large-scale study with 6870 pregnant women from Sweden,
Norway, Denmark, Belgium, Iceland, and Estonia showed that multi-
gravida women with negative birth experiences are five times more
likely to have childbirth fear than pregnant women who had normal
pregnancies (Lukasse et al., 2014). On the other hand, there are other
studies that suggest the previous birth experiences of multiparous
women have no effect on the level of childbirth fear in the current
pregnancy (Fenwick et al., 2015; Toohill, Fenwick, Gamble, & Creedy,
2014). In our study, it has been shown that most of the pregnant women
who remember their previous births happily or proudly have a medium-
level birth fear, whereas those who remember their previous births in
fear or in pain have a lower level of birth fear (see Fig. 2). According to
the results of the study, it was determined that the negative experience
of past births did not cause birth fear in their present pregnancy. Given
that each pregnancy is considered unique, the causes of childbirth fear
of multiparous women can be different from each other, and the
pregnancy can lead to different experiences for multiparous women
(Fenwick et al., 2015).

There is a common belief that multiparous women would have
different expectations because of their previous experiences of giving
birth. However, previous studies surprisingly indicated no significant
differences in the frequency of different expectations between nulli-
parous and mulitparous women except for the variables of ‘body control
in labour’ and ‘control of health decisions’ (Ayers & Pickering, 2005;
Fenwick et al., 2015; Gibbins & Thomson, 2001; Toohill et al., 2014). In
our study, we found that the level of childbirth fear experienced by
multiparous pregnant women who remember their past births nega-
tively is lower than those who remember their past births positively.
Along with their expectations of childbirth, muliparous women can
develop feelings about how they will cope with labour (Gibbins &
Thomson, 2001). However, each childbirth is unique and over-gen-
eralizations about childbirth based on the judgments about past ex-
periences should be avoided. A meeting with the midwife who provided
care in labour can help women fully understand the events of labour
and birth and to help either prevent or identify adverse emotional
outcomes (Gibbins & Thomson, 2001). Multiparous pregnant women
should clearly talk to their midwives and nurses about the excitement,

Table 2
Multinomial logistic regression results.

Level of fear β S.E. exp(β)⁎⁎

Low fear Intercept 0.057 0.239
Happily −1.504⁎ 0.460 0.222
Proudly −0.973⁎ 0.348 0.378
In fear −0.221 0.351 0.801

High fear Intercept −0.391 0.270
Happily −1.526⁎ 0.270 0.217
Proudly 0.672 0.379 0.511
In fear −0.621 0.432 0.538

Note: Level of fear was determined based on the WDEQ-A total scores as:
low=0 to 60 points; moderate= 61 to 84 points; severe= 85 points or above.
“In pain” was chosen as the reference category in previous childbirth experi-
ences (happily, proudly, in fear, in pain).

⁎ p < .05.
⁎⁎ exp is the exponential of β to transform the regression coefficient to an

odds ratio.

O. Korukcu et al. Archives of Psychiatric Nursing 33 (2019) 248–253

251

fear, and anticipation of their new pregnancy. In addition, they should
be aware of the effect of past experiences on coping processes.

It is an important midwifery/nursing duty to identify factors that
make multiparous women feel confident to enable women’s experiences
of childbirth to be satisfying, fulfilling and positive (Fenwick et al.,
2015; Gibbins & Thomson, 2001). The simple act of inviting pregnant
or postpartum women to talk about their childbirth expectations or
experiences is, for most of them, already therapeutic in itself (Van
Bussel, Spitz, & Demyttenaere, 2010). Given that past experiences
predict expectations, the development of optimistic expectations may
be used as a prevention strategy to reduce negative outcomes (Van
Bussel et al., 2010). Healthcare professions should investigate post-
natally how women feel about their experiences (Gibbins & Thomson,
2001).

Implication for future practice

This study has several implications for birth practitioners and
women about the effects of past experiences on future pregnancies in
multiparous women. This study indicated that negative childbirth ex-
periences in the past had led to lower levels of childbirth fear in next
pregnancies among multiparous women. This finding could imply two
possibilities: either expectations are too optimistic, or the provided
antenatal care is of good quality. However, it is not possible to tell from
our data whether this is due to the type of care provider. Thus, further
research is necessary to find out which factors are crucial, and whether
it is a matter of culture or social structure.

Mercer (2004) emphasized that nurses and midwives are the most
communicative people with mothers in maternity circles, and that they
have an important role to play in protecting the health of the mothers
and babies. Birth practitioners should be encouraged to listen to
women, validate their feelings on labour pain, and support them to the
best of their abilities. Exploring multiparous women’s birth experiences
on the level of childbirth fear in current pregnancy is important to gain
a better understanding of childbearing multiparous women’s care needs
and necessary for women-centred care. This study will remind nurses
and midwives that each pregnancy is unique, and thus, deserves a new
starting point for multiparous women. Furthermore, the results of this
study will help nurses and midwives to understand the previous birth
experiences of multiparous mothers on the current birth expectations
and to plan women-centred nursing/midwifery care.

Limitations

The limitations of our study should be addressed. One limitation
was that the study was conducted at a single centre and the sample
group was small. As in similar research studies, the study sample was
composed only of those women willing to take part in a research trial.
The study did not include women who do not speak and write Turkish.
Because of the sample size, the results cannot be representative of the
entire Turkish population. This will also affect the generalizability of
the results. Furthermore, in order to ensure a homogenous sample, and
taking into account that the experiences during the process of transition
to motherhood vary in each pregnancy, only multiparous were included
in the study.

Conclusion

The exploration of women’s experiences and expectations of child-
birth, along with the investigation of how they prepare for childbirth, is
important to help pregnant women better prepare for labour. Previous
negative birth experiences may lead to some negative feelings – such as
fear, anxiety, posttraumatic stress disorders, depressive symptoms,
loneliness, anger, grief, decreased belief in ability to deliver, and re-
duced reliance on caregivers (Nilsson et al., 2010). In conclusion,
contrary to these findings, this study suggests that the level of childbirth

fear experienced by those who remember their previous births nega-
tively is lower than the level of childbirth fear experienced by those
who remember their previous births positively. Learning how to cope
with labour pain and overcoming the fear of obscurity about birth
might improve multiparous women’s psychological wellbeing and
childbirth fear in current pregnancy, even when they have negative
birth experiences (Nilsson et al., 2010). Furthermore, the desire of
pregnancy might be more important than negative birth experiences in
forgetting about negative memories and preparing for a new pregnancy
(Poggi, Goutaudier, Séjourné, & Chabrol, 2018). Midwives should be
aware about pregnant women who experienced a negative birth in their
previous pregnancies might be more realistic in their future pregnancies
and know what to expect from their births. In many cultures, child-
bearing is viewed as the meaning of life and being a mother is the most
important role acquisition for a woman.

In conclusion, women’s previous birth experiences may influence
their future pregnancies. Childbirth fear can persist through the post-
partum period and health care professions need to be alert to addressing
this through sensitive discussions with women about the birthing ex-
perience and their thoughts concerning future births. In Turkey, there is
a need for studies that would enable the standardization of care services
and the establishment routine psychosocial health assessment for
perinatal mental health of women. The results of present study might
help to improve of awareness of health care professions about the ef-
fects of past birth experiences on future pregnancy and psychological
wellbeing of women.

Conflict of interest

No potential conflict of interest was reported by the authors.

Acknowledgment

This study was supported by The Scientific Research Projects Unit of
Akdeniz University, Antalya, Turkey.

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