Investigation into Fear of Birth using a mixed methods design

  • Yana Richens

Student thesis: Phd


Abstract Background: Fear of birth (FOB) is becoming increasingly recognised as a clinical issue that can have profound effects on the mother and her experience of pregnancy and birth. Failure to identify women with FOB could potentially lead to them feeling isolated and unsupported, and impact on their psychological health and the health of their baby. Aim: The main aim of this study was to gain an understanding of FOB and the associated impact on health professional practice, clinical outcomes and women's experiences of birth. The objectives were to: identify the most effective way of measuring FOB in clinical practice; investigate the most appropriate antenatal intervention to support women who fear childbirth; inform the study design for an RCT to assess the effectiveness of the intervention; and assess the most meaningful outcomes to include in future work.Methods: An explanatory mixed-methods study design was used. The first phase was a two-part online survey sent to Heads of Midwifery at 202 maternity units in the UK via Survey Monkey. Respondents were asked to give details of their unit in part 1 and service provision and evaluation for women with FOB in part 2. The second phase was a prospective cohort study of 148 women who had not experienced childbirth who were consecutively attending the Elisabeth Garrett Anderson and Obstetric Hospital, London or St Mary's Hospital, Manchester. Demographic data and details of sources of information on pregnancy were collected from participants in the first trimester along with their score on the tool chosen to measure FOB, the Fear Of Birth Scale (FOBS), and a saliva sample to measure cortisol level. In the third trimester, a second FOBS score and saliva sample were collected, and the Personal Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) were administered to measure depression and anxiety respectively. Birth outcomes for the participants were collected from clinical records. In the third phase, 15 women participating in the second phase were purposively selected to reflect a range of FOBS scores and interviewed by telephone using a semi-structured interview to find out their experiences of pregnancy, being part of the study and service provision.Results: Response rates for the online survey were 63% for part 1 and 54% for part 2. Consultant obstetricians 25% had the most involvement in the care of women with FOB, followed by consultant midwives 21% and 30% had a designated midwife for dealing with FOB and only 32% provided specialist midwifery-led services for women with FOB, with 16% referring to a consultant obstetrician and 47% providing no specialist provision. No unit provided an evaluation of their services, although 19% had undertaken local audits. In the cohort study, using a cut-off of 54 for the FOBS, 30/148 (20%) had a FOB in the first trimester while 21/80 (26%) had a FOB in the third trimester. Compared with the first trimester, 51/80 women showed an increase in FOBS score, with 14 gaining and 7 losing a FOB. FOBS scores were not correlated with salivary cortisol in either trimester but they were correlated with PQH-9 and GAD-7 scores in the third trimester. They were also associated with a previous history of depression but only in the first trimester (p=0.011). FOBS scores showed considerable variability and a high measurement error, indicating a need for further refinement and psychometric testing. The qualitative interviews identified three themes underlying FOB: fearing the worst (pain, fear for the baby and fear of the unknown and complications), pathways to fear (friend-induced fear, mother-induced fear or reassurance and media-induced fear) and igniting or reducing fear (sources of information, support and communication). Conclusions: The FOBS is a potentially effective way of measuring FOB in clinical practice and research, but it requires enhancement informed by the themes identified by this study and psychometric testing in all thr
Date of Award31 Dec 2018
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorMark Wareing (Supervisor), Carol Hindley (Supervisor) & Tina Lavender (Supervisor)


  • FOBS
  • Online Survey
  • Fear of Birth
  • Mixed Methods
  • Screening Tool

Cite this