Introduction: In Western countries, about one pregnant woman in five experiences a considerable fear of childbirth (FOC). Consequently FOC is an important topic for midwives, being pregnant women's main care givers. Also, although many aspects of FOC have been studied, almost no studies have into detail applied a theoretical frame of reference for studying pregnant women's expectations for their upcoming labour and delivery. Therefore, the theory of self-efficacy, here regarding pregnant women's belief in own capability to cope with labour and delivery, has been applied with the aim to better understand the phenomenon of FOC.
Aim: The overall aims of the thesis were to describe midwives' perceptions and views on FOC and to expand the current knowledge about expectations for the forthcoming birth in pregnant nulliparous women in the context of FOC.
Method: Study I had a descriptive design. In total, 21 midwives distributed over four focus-groups, participated. Data were analysed by the phenomenographic approach. Studies II and III had cross sectional designs. Study II comprised 726 midwives, randomly selected from a national sample who completed a questionnaire that addressed the findings from Study I. Study III included 423 pregnant nulliparous women. FOC was measured using the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), self-efficacy by the Childbirth Self-Efficacy Inventory (CBSEI). Study IV had a descriptive interpretative design. Seventeen women with severe FOC were conveniently selected from the sample of Study III and individually interviewed. Content analyses, both deductive and inductive, were performed.
Results: Midwives' perceptions of FOC were related to four description categories, i.e. appearance of FOC, origins of FOC, consequences of FOC and midwifery care (Study I). The midwives thought that the prevalence of FOC has increased in the last ten years at the same time as FOC more often is brought up in the conversations both by women and midwives. There were some significant differences in midwives' views in association with their workplace: antenatal care clinics and labour wards. Midwives working at antenatal care clinics more commonly thought that they lacked sufficient knowledge to support women with severe FOC than midwives working in labour wards (Study II). In pregnant nulliparous women FOC and self-efficacy were found to be associated. The women with severe FOC were more likely to prefer to be delivered by a caesarean section (Study III). Women with severe FOC knew about strategies that are helpful for coping with labour, but they had a limited confidence in the usefulness of these strategies. In addition, they expressed confidence in strategies related to a defined childbirth self-efficacy (Study IV).
Conclusions: Swedish midwives regard severe FOC as a serious problem that influences pregnant women's view on the forthcoming labour and delivery. Midwives at antenatal care clinics, compared to colleagues working at labour wards, experience a greater need for training in care of pregnant women with severe FOC. Self-efficacy is a useful construct and the self-efficacy theory an applicable way of thinking in analysing fear of childbirth. The self-efficacy concept might be appropriate in midwives' care for women with severe FOC.
Key words: Anxiety; Childbirth; Content analysis; Fear; Focus-group interview; Midwives; Self-efficacy; Phenomenography; W-DEQ; CBSEI