Why focus on ‘fear of childbirth'?

Fear of childbirth (FOC) is a common phenomenon in pregnant women. From a psychometrical point-of-view FOC can be seen as a continuum, from almost no fear to extreme fear to give birth. In the latter case, FOC can be so intense that it qualifies for diagnostic terms like 'clinical FOC', i.e. a disabling fear that interferes with occupational or academic functioning, with domestic and social activities or with relationships. The fear may even meet the criteria for a specific phobia according to DSM IV. In some women the fear is specific, and only concerns the event of childbirth. In others, FOC exists in parallel with other types of anxiety problems. In the past decade, a growing interest in this subject has improved our understanding of FOC. New specific measures for FOC are now available to help study FOC and make it easier to compare results from different countries. In recent years research has shown that childbirth can be so traumatic that new mothers fulfil the DSM IV criteria for a posttraumatic stress disorder (PTSD). Research has shown that FOC can be experienced during pregnancy, during delivery and postpartum. Various studies have shown that women who suffer the most from FOC during pregnancy are likely to have the most intense fear during the delivery, and also suffer the most from it afterwards, notwithstanding the kind of delivery. Could this have to do with a self-fulfilling prophecy, i.e. that the woman's appraisal of the impending birth guides her experience during the delivery process? This might also explain why many women with PTSD after childbirth have already displayed PTSD like symptoms before the delivery. PTSD is seen in a high percentage of women after instrumental deliveries and emergency cesarean sections (CS). But, all women will not develop PTSD after a problematic delivery. What is more, the highest incidence of postpartum PTSD is found in the group with obstetrically normal deliveries. These results raise the question how much is postpartum anxiety connected to the very event of delivery and how much of it is related to the woman's psychological functioning. Another question is how much does a woman's anxiety level influence the very process of labor? Studies have shown that FOC, as measured during gestation week 32, is correlated with the occurrence of emergency CS. In addition, women with an anxiety disorder according to DSM IV, more often had an instrumental or emergency surgical delivery than women without. Nevertheless, we know very little about possible links between the level of fear women experience and the physiological functioning during the process of their delivery. A logic theory would be that psychological and physiological processes interact during delivery. The endocrine system is essential for the navigation of the different steps in the delivery process. It is well known that anxiety closely relates to the output of stress hormones. Thus, women's experiences of fear during the delivery may, by means of stress hormones, influence levels of hormones that operate the delivery process. However, when FOC and stress hormones were measured hourly during the process of labor, no systematic correlations were found between the two variables. Could it be that the women's experiences of the delivery and the biological processes in their bodies during birth are after all not connected? Or is this simply an example of the assessment problems of anxiety, i.e. that the three modes of measurement of anxiety (self-report questionnaires, observations of overt behavior and physiological measurements) do not correlate very well? Sound research on