Intended for healthcare professionals

Rapid response to:

Feature Medicine and the Media

Learning from birthing stories on Twitter

BMJ 2019; 364 doi: (Published 12 March 2019) Cite this as: BMJ 2019;364:l1090

Rapid Response:

Increased awareness of fear of childbirth

Despite media spins and ‘hot takes’, fear of childbirth and birth trauma are not new phenomena, but rather has been paid more attention in terms of research and in clinical practice over the last three decades. Women have always had fear of childbirth and it is normal to experience fear of childbirth during pregnancy which may vary at different times (Melender 2002; O’Connell et al 2015). Furthermore, pregnancy is a major life event which may resurrect occult memories of trauma or abuse. There is good evidence of the serious and long term consequences of fear of childbirth on women’s mental health and well-being, and fear can affect decisions made during pregnancy. Critically, in women without a history of depression, women with fear of childbirth are nearly three times more likely to experience postnatal depression (Raisanen 2014). Thus, there needs to be recognition of and treatment of fear and birth trauma as a vital component of high quality maternity care.

Yet, doctors and midwives lack insight into the experience of women with fear of childbirth, which is described similarly on social media via Twitter, as it is in qualitative research studies. Qualitative evidence suggests that there are conflicting media portrayals of pregnancy as a time of happiness and joy versus a time of risk and danger (Luce et al 2016). Given this discourse, it is not surprising that women’s experience in reality may be fearful and stressful. However, reasons for fear of childbirth are complex and may be systems related. Women may fear being left alone in pregnancy or lack of involvement in decision making or lack of control given the uncertain outcome of birth.

Women find it difficult to reveal their fears (Sheen et al 2016) as it goes against the narrative of the radiant, happy pregnant mother. Typically this means that women wait until the fear has festered, manifesting as anger, usually presenting late in pregnancy demanding a CS, which is seen as a panacea. In other cases, women do not feel supported in their preferred choices for birth which results in the rejection of the ‘standard maternity care’ and opt to ‘freebirth’ (Plested and Kirkham 2016). That the latter should happen should make clinicians reflect on our practice. Are we competent and skilled in responding to the needs of women in terms of reducing fear of childbirth? Do we respond with compassion when a woman presents angrily demanding a CS? Do we offer a non-biased discussion of risks and benefits of treatments in a way in which women can understand?

Currently there is no requirement to screen women for fear of childbirth in the UK (Sheen et al 2016). A survey of UK maternity units found that there is a major disparity in the availability of specialist services for women with fear of childbirth (Richens et al 2016). Services which are available have different health care professionals leading and rely on different approaches. Whereas, in other countries, such as Sweden and Finland, fear of childbirth is embedded as a crucial part of routine maternity care. Furthermore, continuity of midwifery care appears to be a feasible option which will help reduce fear (Hildingsson et al 2018).

A recent survey by the Dutch Society of Obstetrics & Gynecology evaluated attitudes of obstetricians and gynaecologists to fear of childbirth and post-partum PTSD (van Dinter-Douma et al 2019) and found a discrepancy in the experience of women and the way doctors perceived their own attitudes. van Dinter-Douma et al (2019) identified a lack of clarity for doctors in terms of a clear international protocol for Caesarean Section at maternal request and a lack of training in recognising and addressing fear of childbirth and birth trauma. Therefore, there is an urgent need for training of maternity staff in relation to sensitive, trauma informed care. From the discourses on social media and the qualitative evidence, it is clear that there is a contrast between how women experience their care and how clinicians feel care is given. While it may be difficult to follow hashtags like #metoointhebirthroom, clinicians need to not take this personally, but rather take an objective and evidence-based approach. There needs to be a call to action to increase awareness of fear of childbirth and birth trauma to reduce stigma for women in discussing their fears. In addition, there is a need to normalise the conversation about fear of childbirth in pregnancy and increase the availability of support to women.

Hanna‐Leena Melender, R.M., 2002. Experiences of fears associated with pregnancy and childbirth: a study of 329 pregnant women. Birth, 29(2), pp.101-111.
Hildingsson, I., Rubertsson, C., Karlström, A. and Haines, H., 2018. Caseload midwifery for women with fear of birth is a feasible option. Sexual & reproductive healthcare, 16, pp.50-55.
Luce, A., Cash, M., Hundley, V., Cheyne, H., Van Teijlingen, E. and Angell, C., 2016. “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC pregnancy and childbirth, 16(1), p.40.
Plested, M. & Kirkham, M. 2016. Risk and fear in the lived experience of birth without a midwife Midwifery, 38, 29-34.
O'Connell, M., Leahy-Warren, P., Khashan, A.S. and Kenny, L.C., 2015. Tocophobia–the new hysteria?. Obstetrics, Gynaecology & Reproductive Medicine, 25(6), pp.175-177.
Räisänen, S., Lehto, S.M., Nielsen, H.S., Gissler, M., Kramer, M.R. and Heinonen, S., 2013. Fear of childbirth predicts postpartum depression: a population-based analysis of 511 422 singleton births in Finland. BMJ open, 3(11), p.e004047.
Richens, Y., Hindley, C. and Lavender, T., 2015. A national online survey of UK maternity unit service provision for women with fear of birth. British Journal of Midwifery, 23(8), pp.574-579.
van Dinter-Douma, E.E., de Vries, N.E., Aarts-Greven, M., Stramrood, C.A. and van Pampus, M.G., 2018. Screening for trauma and anxiety recognition: knowledge, management and attitudes amongst gynecologists regarding women with fear of childbirth and postpartum posttraumatic stress disorder. The Journal of Maternal-Fetal & Neonatal Medicine, pp.1-9.

Competing interests: No competing interests

13 March 2019
Maeve A O'Connell
Lecturer in Nursing
Royal College of Surgeons Ireland in Bahrain, Irish Centre for Fetal and Neonatal Translational Research (INFANT Centre), University College Cork
Adliya, Bahrain