Title: Evaluating the properties of the Fear of Childbirth Questionnaire and feasibility of routine implementation for maternity services
Funder: Department of Health and Social Care

Abstract: Background. Fourteen percent of pregnant women report severe fear of childbirth (FOC), resembling a phobia of giving birth. Fear influences decisions made about birth, increasing epidural or elective caesarean requests. Heightened antenatal anxiety is associated with longer labour, preterm birth and birth intervention, and can influence infant development. Women with FOC are more likely to experience birth as traumatic increasing risk for postpartum posttraumatic stress disorder. FOC is not routinely identified in antenatal care. The National Institute for Health and Care Excellence recommendations include screening for anxiety and depression, but not all women will be identified this way. Early access to support is essential, but this requires effective identification. There are currently no accurate, acceptable tools to measure FOC with UK populations. We have systematically developed a new tool, the Fear of Childbirth Questionnaire (FCQ). This was developed closely with women to reflect their own lived experience of FOC, and to address the full FOC construct. This project provides the next stage of development towards a screening tool for general service implementation, by providing the means and process for accurately identifying fear in maternity services. Aims and objectives. To 1) evaluate the psychometric and clinical properties of the FCQ assessing validity and reliability, and 2) examine feasibility of routine use in maternity services and explore acceptability for women and midwives. Methods. This project involves two stages. Stage 1 involves an online survey. Women (N=420) will be invited to complete the FCQ alongside additional measures for anxiety and depression. The majority of women (N=360) will then participate in a structured clinical telephone interview to examine clinically relevant fear. Remaining women (N=60) will be asked to repeat the FCQ two-weeks later to assess test-retest reliability. Stage 2 will evaluate feasibility of using the FCQ in maternity services. We will train community midwives (N= 40) in the use and interpretation of the FCQ. Over a six-week period, women (N= 100) will receive the FCQ at booking, complete this at home and bring it to their 16-week antenatal visit. We will examine acceptability via interviews/focus groups with women and midwives. Practicality, uptake and barriers to implementation will be recorded. Timeline. This 27-month project will produce a fully-validated tool for use in clinical services, with identification of clinical thresholds, that will be freely available for NHS maternity services. It will identify and shape a feasible process for simple integration of FCQ use into maternity care. Anticipated impact and dissemination. This project will provide a simple method of accurately identifying FOC, enhancing access to existing support. This will help women to experience pregnancy without disabling levels of fear, benefitting their mental health and infant development. It will benefit services by preventing fear-driven costly interventions and benefit society by reducing costs from untreated perinatal mental health conditions. We will share the FCQ with local maternity mental health services, and liaise with local and national service-user and maternity groups. Future progression will use the parameters identified to test benefits of routine implementation for women and maternity services.

Lay abstract: Aim To provide an accurate way to identify women who experience fear of childbirth (FOC) during pregnancy in routine maternity care. Background. One in seven pregnant women experience severe fear of childbirth (FOC), causing high day-to-day distress. Women with FOC are more likely to experience birth trauma and posttraumatic stress disorder after birth. Women with FOC may ask for a caesarean section, are more likely to give birth prematurely and need birth interventions. FOC can increase stress hormones, which can affect how the unborn baby develops. These all increase NHS costs. Pregnant women are asked about general feelings of anxiety and depression, but not fear of childbirth. FOC is not the same as general anxiety, and those with FOC are missed with the current questions. Better ways of identifying FOC are needed. Previous and planned work. We spoke to pregnant women and clinical staff about the parts of birth that are mainly feared. We looked with women at whether current questionnaires were clear and acceptable, and if they asked about each of the main fears. No questionnaire was both acceptable and asked about each main fear, and so the new Fear of Childbirth Questionnaire (FCQ) was developed. We now need to test how reliable the FCQ is and see if it measures what we think it does. We will recruit a large number of pregnant women online to complete the FCQ. We will also complete diagnostic interviews to identify whether (and at what point) scores on the FCQ suggest clinical levels of fear. Then, we will test a new way of asking women to complete the FCQ early in pregnancy during routine care and see how acceptable this is. If we can identify women experiencing FOC early, we can improve early access to support. This could reduce the likelihood of birth outcomes we know that are more likely after a stressful pregnancy, such as premature birth. This can benefit women s mental health and lower maternity service costs. Patient and Public involvement. The FCQ was developed during a project with strong integrated input from members of the public with lived experience. Six members of the public with FOC have shaped this application, providing guidance on how the FCQ could benefit for pregnant women. Our PPI Co-Investigator will link with members of the public and services to share study progress. Dissemination We will share findings with local maternity networks, new maternity mental health services, maternity voices partnerships. On a national level, we will share findings with the consultant midwife network, national clinical network meetings, and with the FutureNHS Platform. We will plan the next project to see if adopting the FCQ into usual care directly benefits women, babies, and maternity services.

Research activity codes: 4.4 POPULATION SCREENING
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH;MENTAL HEALTH