Journal of Psychosomatic Obstetrics & Gynecology

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A cluster analysis of reasons behind fear of birthamong women in Sweden
Ingegerd Hildingsson & Margareta Johansson
To cite this article: Ingegerd Hildingsson & Margareta Johansson (2024) A cluster analysis ofreasons behind fear of birth among women in Sweden, Journal of Psychosomatic Obstetrics &Gynecology, 45:1, 2319291, DOI: 10.1080/0167482X.2024.2319291
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Journal of Psychosomatic Obstetrics & Gynecology
2024, VOL. 45, NO. 1, 2319291
https://doi.org/10.1080/0167482X.2024.2319291

Research Article

A cluster analysis of reasons behind fear of birth among women in
SwedenIngegerd Hildingssona,b and Margareta Johanssona
Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden; bDepartment of Nursing, Mid Sweden University,
Sundsvall, Swedena

ARTICLE HISTORY

ABSTRACT

Background: Fear of birth is common and complex, caused by a variety of reasons. The aim was
to investigate the prevalence of pre-established reasons in relation to fear, and to identify profilesof women based on their reported reasons behind fear of birth.
Methods: A cross-sectional Swedish study of women with self-reported fear of birth whocompleted an online survey. Descriptive statistics, chi-square test, crude and adjusted odds ratioswith 95% confidence intervals were used in the analysis of pre-established reasons in relation toself-reported severe fear. A Kappa-means cluster analysis was performed in order to groupreasons, that were further investigated in relation to women’s background variables.
Results: A total of 1419 women completed the survey. The strongest reason behind fear of birth
was to be forced to give birth vaginally. Four clusters were identified and labeled: minor complexity(reference group), relative minor complexity, relative major complexity, and major complexity.
Cesarean section preference, previous mental health problems, being younger, primiparity, andexposure to domestic violence were factors related to cluster grouping.
Conclusions: Women with fear of birth have various reasons and diverse complexities behind
their fear. Health care providers need to investigate these reasons and support pregnant womenwith childbirth fear, based on their needs.

Introduction
The body of research around fear of birth is growing.
Although the phenomenon ‘fear of birth’ does nothave a clear definition [1,2], it is commonly used inclinical practice [3], research [4,5], media [6], andamong women [7,8].
The prevalence of fear of birth depends on how it
is measured, with no consensus as to the best method,
although governmental initiatives (such as that in
Sweden) have suggested that using a Visual Analogue
Scale (VAS) scale or similar instrument might be helpful in identifying women with fear of birth [3]. Previous
research has shown a prevalence of 10–20% in studies
conducted in high-resource countries [9], and ameta-analysis concluded that 14% of pregnant women
worldwide suffer from fear of birth [2].
Another topic of interest is the reasons behind fearof birth. A systematic review based on 21 studies [10]CONTACT Ingegerd Hildingsson
Swedeningegerd.hildingsson@kbh.uu.se

Received 11 December
2023
Revised 10 February 2024
Accepted 11 February
2024
KEYWORDS

Cluster analysis; fear ofbirth; parity; reasons;survey; womengrouped such reasons into population characteristics,
mood-related aspects, and reasons related to pregnancy and childbirth. Many of the studies focusing on
population characteristics have presented contradictory results in terms of age, social support, ethnicity,level of education, and parity. The mood-related
aspects related to fear of birth are reported to include
stress, anxiety, depression, mental health problems,and abuse. Reasons related to pregnancy and childbirth—including infertility problems, negative birthexperiences, prolonged labor duration, epidural use,and emergency cesarean section (CS)—were other factors associated with fear of birth [10]. Results regarding fear of birth and elective CS [10–12] andinstrumental vaginal birth [10] have been contradictory. Other studies have shown that labor augmentation with oxytocin, transfer of the baby to a neonatal
intensive care unit, and long distance to the hospital

Uppsala University, Department of women’s and children’s health, Uppsala,© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the
Accepted Manuscript in a repository by the author(s) or with their consent.

2

I. HILDINGSSON AND M. JOHANSSON

increased fear of birth [13]. Other reasons reported as
being related to fear of birth include lack of confidence in the ability to give birth, fear of the unknown,other women’s birth stories, fear of perineal tearing,
unmet needs around information and support, loss ofcontrol, not being involved in decision-making, bloodand injection phobias, fear of pain, and low selfesteem [14].
Scant literature examines the impact of encounterswith health care providers and support from the partner on reasons for fear of birth. Therefore, the aim of
the current study was to investigate the prevalence ofpre-defined reasons related to fear of birth and to
identify and explore clusters of reasons related to parity and various background variables.

Material and methods
DesignThis cross-sectional study was approved by the regional
ethical committee in Sweden on August 24, 2021 (Dnr
2021-03759). The study procedure was guided by the
STROBE checklist [15], and it involved participants
completing an online survey.

Process and recruitment of participants
Inclusion and exclusion criteria
The present study recruited women, regardless of any
previous pregnancy, with fear of birth and knowledgeof the Swedish language. Women younger than
18 years of age and not living in Sweden were
excluded.
Recruitment process
Information about the study was available via posters
at ultrasound clinics, at counseling clinics for fear ofbirth at six hospitals in Sweden between February
2022 and September 2022. Potential participants werehanded a study information leaflet with a web link
and QR (Quick Response) code for the survey. In addition, advertisements were posted on social media (i.e.
Facebook and Instagram), and in newsletters of nonprofit organizations for pregnant women. At the bottom of the advertisements, a web link and/or QR code
to the online survey were presented.
Informed consent
After clicking the link, potential participants weretransferred to Research Electronic Data Capture[RedCap], which is hosted at Uppsala University.

RedCap is a secure, web-based software platform
designed to support data collection in research studies[16]. Study information, including the purpose of theresearch and the principles of voluntary participationand confidentiality of data was presented. Participants
were informed that by clicking “yes”, they consented toparticipate in the survey. The survey was completed
anonymously after providing consent.

Instrument
Variables included in the survey
The survey comprised a variety of questions, of whichsome are used in the present study. Fear of birth, wasassessed using one question To what extent do you
experience fear of birth?, assessed on a 4-point Likert
scale with the response options ‘to a very large extent’,‘to a large extent’, ‘to a small extent’, and ‘not at all’.
We also used the Fear of Birth Scale (FOBS) [17,18].
The FOBS consists of two 100-mm Visual Analog
Scales (VAS), with the anchor spectra ‘Calm–Worried’and ‘No fear–Strong fear’, and is preceded by a question How do you feel right now about the approachingbirth? Women placed a mark on each of the scales,
which were measured, summed, and averaged to get
the FOBS score; a score of 60 or more was used toclassify women as having fear of birth. The prevalenceof Fear of birth using FOBS (with a cutoff 60 or more)in population-based pregnant populations is around20%. The Cronbach alpha value was 0.929, correlation
between the subscales 0.85 [18].
One section of the survey presented a set ofpre-established listed reasons for experiencing fear ofbirth. The reasons were related to labor and birth (i.e.
that they would die, having a vaginal instrumental
birth), internal factors (i.e. becoming dependent onother people, feelings of helplessness, powerlessness,
dependency, inability to give birth, uncertainty), thebaby (i.e. having a sick baby), encounters with healthcare providers (i.e. being forced to give birth vaginallyagainst will, not receiving sufficient information, notbeing taken seriously, not being respected, not being
involved in the care, not being listened to), the partner (i.e. not being available to attend antenatal visits,
partner having fear of birth, lack of support frompartner), and other reasons (i.e. unsuccessful breastfeeding, worried about fainting). Women selected therelevant reasons by ticking the box next to the presented reasons.
Sociodemographic background explanatory variables were: age, civil status, country of birth, residential area, level of education, previous pregnancies (i.e.
miscarriage, previous mode of birth) and current

Journal of Psychosomatic Obstetrics & Gynecology

pregnancy, previous and current mental health problems, and exposure to domestic violence.

Statistical analyses
Descriptive statistics were used to present participants’reasons behind their fear of birth, as well as background variables. Comparisons were made between
nulliparous and parous women using chi-square tests.
The pre-established reasons for fear of birth were firstinvestigated in relation to severe fear of birth (ananswer of ‘to a very large extent’ to the question To
what extent do you experience fear of birth?). Thereafter,
the pre-established reasons were grouped, summed,
and transformed into z-scores. A nonhierarchicalKappa–means cluster analysis was performed to groupthe pre-established reasons to describe the levels ofcomplexity of the fear. The goal of the cluster analysis
was to split up the large set of variables into smaller
and more homogeneous groups. Given the exploratory
nature of cluster analysis other possible solutions of
two-cluster and three-cluster solutions were also evaluated. The four-cluster solution was found to offer themost interpretable and clinically meaningful solution.
Each cluster was labeled according to the grouping of
its items after discussions among the authors. The
next step was to calculate odds ratios (OR) with 95%
confidence intervals (CI) between the clusters and thebackground variables. The variables age, residentialarea, previous miscarriage, previous mental healthproblems, and being currently pregnant were statistically different between nulliparous and parous women
and were therefore selected as potential confounders
in calculating the OR.

Results
In total, 711 nulliparous (50.1%) and 708 parous(49.9%) women with fear of birth completed the questionnaire. Table 1 shows the background informationof the participants. The majority were 25–35 years old,
living with a partner, born in Sweden, and had a university education. Parous women were more likely to
exhibit severe fear of birth, or fear of birth ‘to a verylarge extent’, compared to nulliparous (p = 0.002).
Nulliparous women were more likely to report previous mental health problems compared to parous
women (p = 0.008), but no differences were found incurrent mental health problems or exposure to domestic violence. In addition, parous women were older
than nulliparous women (p < 0.001) and less likely tolive in a city (p < 0.001). Parous women were also more3

likely to have had a previous miscarriage (p < 0.001)
and were less likely to be pregnant at the time ofcompletingthesurvey(p < 0.001).
Women’s
self-assessment of their fear of birth showed that
15.7% of the primiparous and 24% of the multiparous
women reported the fear at ‘a very large extent’,(p < 0.001). The corresponding figures for presenting
with a FOBS-score of 60 or more were 61.9% and 67.
2%, non-significant difference.
Table 2 provides a detailed presentation of thelisted pre-established reasons for fear of birth inwomen who exhibited severe fear, compared to
women without severe fear as the reference, with theprevalence of each reason and the crude and adjusted
ORs for the estimations of the strength of the associations. Nulliparous and parous women both reported
that the reasons related to labor and birth were primarily that they themselves would die, along with therisk of having a vaginal instrumental birth.
Results on the reasons related to internal factors inwomen with severe fear reveal that the only reason
nulliparous women reported was fear of becoming
dependent of other people, while parous women’sinternal reasons included feelings of helplessness,
powerlessness, dependency, inability to give birth, anduncertainty in relation to severe fear of birth.
The listed pre-established reasons related to thebaby showed no association with severe fear in parous
women, while nulliparous women were less likely toreport having a sick baby as a reason for their fear.
Results on the reasons related to encounters withhealth care providers showed that the strongest association with severe fear was being forced to give birthvaginally against will, with ORs of 7.98 in nulliparous
women and 5.59 in parous women. Nulliparous
women were less likely to report ‘not receiving sufficient information’ as a reason but were more likely toreport ‘not being taken seriously’ or ‘not being
respected’ as reasons for their fear. Parous women
also reported fear related to ‘not being taken seriously’ and ‘not being respected’ as reasons associatedwith severe fear of birth, as well as ‘not being involvedin the care’ or ‘not being listened to’.
‘Partner not being available to attend antenatal
visits’ was associated with fear in nulliparous women,
while ‘partner having fear of birth’ showed lower
odds. Parous women were less likely to report ‘lackof support from partner’ as a reason behind fearof birth.
Of the reasons grouped as ‘other’, nulliparous
women were less likely to report ‘unsuccessful breastfeeding’ as a reason for fear, and parous women were
worried about ‘fainting’.

4

I. HILDINGSSON AND M. JOHANSSON

Table 1. Background of the participantsa.

Socio-demographic backgroundAge groups
19–30 years
31–35 years
36–53 years
Civil status
Living with a partner
Not living with a partner
Country of birth
SwedenOther country
Level of education
High school or lower
University education
Residential area
City
Larger community
Smaller village
Obstetric characteristics
Obstetric history b
Previous live birthPrevious stillbirthPrevious miscarriage
Previous abortion
Currently pregnant
YesNo
Gestational weeks
18 or less
19–36 weeks
37 or more
Self-reported status of the current pregnancy
NormalNot normal
Self-reported fear of birth
To a very large extent
To a large extent
To a small extent
Not at all
Fear of Birth Scale (FOBS)
Mean, (SD)
FOBS 60 or more
Preferred mode of birth
Vaginal
Cesarean section
Don’t know
Mental healthPrevious mental health problems
Yes
No
Current mental health problems
Yes
No
Previous or current exposure to domestic violence
YesNoa
Numbers might not reach 100% due to internal missing values.
bParous women only.

In a subsequent step, a cluster analysis was performed of the pre-established listed reasons related tolabor and birth, internal factors, the baby, encounterswith health care providers, the partner, and ‘other’,after the reasons were summed for each group of reasons. The summed variables were standardized before
the analysis was performed. Four distinct clusters
appeared which describe the level of complexity of

p-value

Nulliparous womenn = 711n (%)

Parous womenn = 708n (%)

210 (29.8)350 (50.1)
142 (20.2)

96 (13.7)
310 (44.3)
294 (42.0)<0.001678 (95.5)
32 (4.5)672 (95.0)
35 (5.0)0.709

646 (91.2)
62 (8.8)632 (89.4)
75 (10.6)

0.244

122 (17.2)
588 (82.8)

123 (17.4)
583 (82.6)

0.944

518 (73.1)
106 (15.9)
85 (12.0)452 (63.8)
133 (18.8)
123 (17.4)<0.001136 (19.1)
153 (21.5)

699 (98.7)
17 (2.4)
196 (27.7)
144 (20.3)

nana<0.0010.525

679 (95.6)
31 (4.4)

416 (58.8)
291 (41.2)<0.001159 (24.5)
369 (56.8)
122 (18.8)

104 (25.1)
222 (53.6)
88 (21.3)

0.525

595 (91.1)
58 (8.9)364 (87.3)
53 (12.7)

0.051

93 (25.0)
173 (46.5)
104 (28.0)
2 (0.5)120 (34.3)
149 (42.6)
72 (20.6)
9 (2.6)0.002

62.98 (27.20)
373 (61.9)

64.44 (30.03)
350 (67.2)

0.394
0.070

450 (69.1)
104 (16.0)
97 (14.9)282 (67.8)
75 (18.0)
59 (14.2)

0.673

382 (60.2)
253 (39.8)

320 (52.7)
287 (47.3)

195 (30.8)
438 (69.2)

187 (30.8)420 (69.2)

112 (17.7)
520 (82.3)

108 (17.9)
496 (82.1)

0.008

1.000
1.000

the fear; these were explored and labeled as (i) minor
complexity, (ii) relative minor complexity, (iii) relative
major complexity, and (iv) major complexity (Figures
1 and 2).
The first cluster, labeled minor complexity, was used
as a reference group. This cluster, comprising 286 participants, was characterized by a mean FOBS score of
80.09 (SD 12.02) and showed negative levels ofJournal of Psychosomatic Obstetrics & Gynecology

5

Table 2. Reported reasons behind fear of birth in women with severe feara.
Reported reasons

Reported reasonsPrimiparasin women with

Reasons in relation
to labor and birth
Prolonged labor
Severe ruptures
Risk of dying
Instrumental vaginal
birth
Cesarean section
Infection
Reasons in relation
to inner self
LonelinessHelplessness
Powerlessness
Dependency
FailureLoss of control
Unbearable pain
Inability to manage
labor pain
Inability to give birth
Uncertainty
Reasons in relation
to the baby
Baby getting infection
Admission to hospital
Baby being sick
Birth injuries
Death of the baby
Reasons in relation
to encounter withhealth careprovidersBeing forced to givebirth vaginally
Unavailable hospital of
choiceStopped from being
admitted to hospitalNot receiving pain relief
Not receiving support
Not receiving propercare
Not receiving
information
Not being involved
Not being treated withrespect
Not being taken
seriously
Not being listened toReasons related tothe partner
Not allowed to bepresent during
antenatal visits
Not allowed to bepresent during laborand birth
Not receiving support
during pregnancy
and birth
Not receiving support
during parenthoodPartner being fearful
Reasons related toother aspects
To see blood
To receive injections

Multiparasin women withsevere fearn (%)

Crude OR(95% CI)

Adjusted OR(95% CI)severe fearn (%)

Crude OR(95% CI)

Adjusted OR(95% CI)

57 (61.3)
78 (83.9)
51 (54.8)
64 (68.8)

1.07 (0.66–1.74)
0.84 (0.44–1.61)
2.59 (1.60–4.18)***2.52 (1.53–4.16)***1.04 (0.63–1.71)
0.79 (0.41–1.54)
2.58 (1.57–4.23)***
2.59 (1.55–4.33)***63 (52.5)
91 (75.8)
60 (50.0)60 (50.0)

1.22 (0.78–1.90
1.37 (0.83–2.71)
1.87 (1.19–2.93)**
1.94 (1.24–3.05)**

1.22 (0.78–1.90
1.34 (0.79–2.25)
1.92 (1.20–3.09)**
1.89 (1.19–3.00)**

29 (31.2)
8 (8.6)0.98 (0.59–1.63)
1.65 (0.67–4.04)

1.15 (0.68–1.94)
1.46 (0.58–3.68)

35 (29.2)
7 (5.8)0.81 (0.50–1.32)
1.36 (0.50–3.67)

0.85 (0.52–1.40)
1.95 (0.68–5.59)

38 (40.9)
61 (65.6)
66 (71.0)
40 (43.0)
29 (31.2)
62 (66.7)
60 (64.5)
58 (62.4)

1.50 (0.92–2.43)
1.37 (0.84–2.24)
1.56 (0.94–2.60)
2.34 (1.43–3.83)***0.87 (0.53–1.45)
1.22 (0.74–2.00)
0.95 (0.58–1.55)
0.84 (0.51–1.37)

1.45 (0.87–2.42)
1.40 (0.84–2.35)
1.48 (0.87–2.52)
2.27 (1.36–3.78)***0.81 (0.47–1.37)
1.24 (0.74–2.08)
0.94 (0.56–1.56)
0.83 (0.50–1.38)

54 (45.0)
92 (76.7)
85 (70.8)
45 (37.5)
36 (30.0)66 (55.0)
65 (54.2)
64 (53.3)

1.32 (0.84–2.06)
1.29 (0.81–2.07)
3.11 (1.90–5.12)*** 3.25 (1.94–5.44)***1.70 (1.06–2.74)* 1.68 (1.03–2.76)*
2.33 (1.43–3.51)*** 2.35 (1.41–3.90)***1.11 (0.68–1.80)
1.17 (0.70–1.96)
1.24 (0.79–1.93)
1.25 (0.78–1.98)
1.06 (0.68–1.65)
1.08 (0.68–1.71)
1.22 (0.78–1.90)
1.19 (0.75–1.88)

45 (48.4)
71 (76.3)

1.12 (0.69–1.85
1.48 (0.86–2.55)

1.13 (0.69–1.85
1.58 (0.90–2.77)

51 (42.5)
85 (70.8)

1.65 (1.04–2.61)*
1.64 (1.02–2.64)*

1.78 (1.10–2.68)*
1.64 (1.01–2.68)*

15 (16.1)
28 (30.1)
47 (50.5)
78 (83.9)
69 (74.2)

1.53 (0.79–2.99)
0.65 (0.39–1.07)
0.55 (0.34–0.89)*
1.33 (0.71–2.49)
1.32 (0.78–2.24)

1.61 (0.81–3.19)
0.66 (0.40–1.11)
0.52 (0.31–0.86)*
1.39 (0.73–2.66)
1.37 (0.79–2.37)

15 (12.5)
48 (40.0)66 (55.0)
90 (75.0)
93 (77.5)

0.91 (0.47–1.77)
1.32 (0.83–2.09)
0.90 (0.58–1.41)
0.89 (0.53–1.50)
1.44 (0.86–2.41)

0.89 (0.45–1.77)
1.42 (0.88–2.28)
0.97 (0.61–1.53)
0.90 (0.53–1.53)
1.52 (0.89–2.61)

68 (73.1)

6.22 (3.69–10.48)*** 7.98 (4.59–13.90)***79 (65.8)

5.98 (3.69–9.70)*** 5.59 (3.40–9.18)***34 (36.6)

1.13 (0.69–1.85)

1.09 (0.65–1.82)

39 (32.5)

1.42 (0.88–2.31)

1.37 (0.83–2.27)

45 (48.4)

0.95 (0.59–1.53)

0.90 (0.55–1.46)

57 (47.5)

1.21 (0.78–1.89)

1.19 (0.75–1.88)

42 (45.2)
61 (65.6)
61 (65.6)

1.06 (0.66–1.69)
0.79 (0.48–1.30)
0.89 (0.54–1.46)

1.04 (0.64–1.70)
0.75 (0.44–1.27)
0.87 (0.52–1.45)

51 (42.5)
87 (72.5)
74 (61.7)

1.17 (0.74–1.83)
1.20 (0.73–1.95)
1.37 (0.87–2.15)

1.01 (0.63–1.61)
1.19 (0.72–1.98)
1.40 (0.88–2.24)

59 (63.4)

0.55 (0.13–0.74)**

0.58 (0.35–0.98)*

78 (65.0)

1.58 (1.00–2.50)

1.52 (0.94–2.45)

63 (67.7)
63 (67.7)

1.51 (0.92–2.48)
1.72 (1.05–2.83)*

1.40 (0.84–2.33)
1.69 (1.02–2.80)

75 (62.5)
69 (57.5)

1.63 (1.04–2.57)*
1.50 (0.96–2.34)

1.59 (0.99–2.55)
1.68 (1.04–2.70)*

72 (77.4)

2.23 (1.29–3.83)**

2.21 (1.26–3.88)**

78 (65.0)

1.61 (1.02–2.34)*

1.64 (1.02–2.63)*

65 (69.9)

1.58 (0.95–2.61)

1.51 (0.90–2.54)

81 (67.5)

1.87 (1.17–2.96)**2.08 (1.28–3.39)**

26 (28.0)

1.77 (1.02–3.07)*

1.64 (0.91–2.93)

31 (25.8)

1.60 (0.94–2.72)

1.56 (0.90–2.72)

56 (60.2)

1.15 (0.71–1.86)

1.16 (0.76–1.90)

66 (55.0)

1.00 (0.64–1.57)

1.07 (0.68–1.70)

23 (24.7)

0.64 (0.38–1.10)

0.69 (0.40–1.19)

26 (21.7)

0.60 (0.36–1.01)

0.58 (0.34–0.99)

13 (14.0)

0.69 (0.35–1.33)

0.68 (0.35–1.35)

11 (9.2)

0.69 (0.33–1.45)

0.68 (0.32–1.46)

6 (6.5)0.37 (0.15–0.92)*

0.38 (0.15–0.94)*

8 (6.7)0.61 (0.26–1.41)

0.59 (0.25–1.40)

15 (16.1)
18 (19.4)

1.14 (0.60–2.19)
0.85 (0.47–1.54)

1.21 (0.61–2.37)
0.86 (0.47–1.58)

10 (8.3)
17 (14.2)

1.81 (0.74–4.39)
1.41 (0.72–2.75)

1.59 (0.62–4.08)
1.55 (0.77–3.10)(Continued)

6

I. HILDINGSSON AND M. JOHANSSON

Table 2. Continued.
Reported reasons

Reported reasonsPrimiparasin women withsevere fearn (%)

Crude OR(95% CI)

Adjusted OR(95% CI)severe fearn (%)

To faint
11 (11.8)
0.63 (0.31–1.26)
0.56 (0.26–1.19)
13 (10.8)
Sex life being affected
45 (48.4)
1.00 (0.62–1.59)
0.90 (0.55–1.47)
47 (39.2)
Not succeed with20 (21.5)
0.36 (0.21–0.62)*** 0.37 (0.21–0.66)***26 (21.7)
breastfeeding
Not being a good29 (31.2)
0.86 (0.52–1.42)
0.82 (0.48–1.38)
16 (13.3)
parentOthers’ stories
46 (49.5)
1.00 (0.62–1.59)
1.04 (0.64–1.70)
34 (28.3)
Unable to take care of
34 (36.6)
1.04 (0.64–1.70)
1.01 (0.61–1.68)
41 (34.2)
the baby
Don’t know any reason
12 (12.9)
1.57 (0.75–3.28)
1.65 (0.78–3.52)
4 (3.3)*=p < 0.05, **=p < 0.01, ***=p < 0.001.
Adjusted for age, residential area, previous miscarriage, previous mental health problems, currently pregnant.
aRef = Women assessing fear as not severe.

reasons related to health care providers and the partner along with low levels of internal reasons, the baby,
and other reasons.
The second cluster, labeled relative minor complexity,
comprised 144 women and had a mean FOBS score of
80.64 (SD 11.58). Women in this cluster had moderatelevels of reasons related to encounters with healthcare providers and the partner, a few reasons related
to internal factors, and negative levels of reasons
related to the baby and other.
The third cluster, labeled relative major complexity,
had a mean FOBS score of 85.67 (SD 12.35) and comprised 145 women. This cluster was characterized bylow levels of reasons related to the partner and ‘other’reasons along with moderate to high levels of reasons
related to the birth, internal factors, the baby, andhealth care providers.
Finally, the fourth cluster, major complexity, comprised 148 women and had a mean FOBS score of
83.18 (SD 11.73). This cluster showed moderate to highlevels of all grouped reasons, with the highest scoresfor reasons related to the partner and ‘other’.
Each cluster was then compared with the referencegroup (minor complexity) in relation to the backgroundvariables presented in Table 1. No differences were
found in any of the background variables when minor
complexity and relative minor complexity were compared. When relative major complexity was comparedwith minor complexity, women in the relative majorcomplexity cluster more often wished to have a CS
(OR 2.63; CI 1.55–4.47) and were more likely to have
had previous mental health problems (OR 1.86; CI
1.23–2.82). Finally, compared to the minor complexity
cluster, women in the major complexity cluster wereyounger (OR 0.53; CI 0.30–0.93), less likely to havegiven birth before (OR 0.40; CI 0.26–0.61), had previous mental health problems (OR 2.06; CI 1.37–3.11),

Multiparasin women with
Crude OR(95% CI)

Adjusted OR(95% CI)

2.98 (1.23–7.19)**
1.47 (0.92–2.33)
0.82 (0.48–1.38)

3.09 (1.20–7.90)*
1.38 (0.85–2.22)
0.94 (0.54–1.64)

0.91 (0.48–1.74)

0.82 (0.41–1.62)

1.12 (0.68–1.83)
1.43 (0.89–2.31)

0.95 (0.56–1.60)
1.45 (0.88–2.39)

0.43 (0.14–1.31)

0.38 (0.12–1.20)

and were more likely to have been exposed to domestic violence (OR 2.10; CI1.31–3.37).

Discussion
The main findings of the present study highlighted
some similarities and some differences between nulliparous and parous women who reported reasons fortheir fear of birth. Similarities were found in fears ofdying, of having an instrumental vaginal birth, and ofbeing dependent. The greatest similarities were foundin the encounters with the health care providers, withworries about being forced to give birth vaginallyshowing the highest likelihood of severe fear. Other
important similarities were fear of not being treatedwith respect, not being taken seriously, and not being
listened to.
According to the present study, both nulliparousand parous women reported that being forced to givebirth vaginally against their will, was a reason behind
their fear of birth. Previous studies have shown thatstrategies used to avoid having to go through a vaginal birth are avoiding pregnancy [19] or requesting
elective CS as the mode of birth [19,20]. Women who
preferred a CS often regarded vaginal birth as risky
and CS as a safe mode of birth associated with little orno risk [20,21]. These women would rather encounter
acceptance in response to their request than receive
information about risks [20]. Women considered themselves as having the right to demand a non-medical
CS as a result of their well-reasoned request [20,21]. In
contrast, clinicians held wide-ranging and conflicting
views on the extent to which a woman has the rightto choose the mode of birth herself [20].
Women in the present study reported fears of not
being treated with respect, not being taken seriously,
and not being listened to as reasons behind their fear

Journal of Psychosomatic Obstetrics & Gynecology

7

Figure 1. Cluster based on reported reasons among primiparous women.

Figure 2. Clusters based on reported reasons in multiparous women.

of birth. A meta-synthesis of seven qualitative studies
described how women feared not being treated with
dignity during childbirth; however, an intervention byteam midwifery helped women develop confidence inthemselves and in health care providers, which helped
them cope with labor and birth [1]. Anothermeta-synthesis of 22 studies investigated women’s
experiences of disrespect due to health care providers’attitudes during childbirth. Women felt lonely when
they were not given attention, support, or an explanation of medical interventions carried out during labor,or an opportunity to express their wishes. In this kindof experience, women felt disrespected, unimportant,neglected, abandoned, and dehumanized [22]. In contrast, women felt respected and valued when clinicianslistened to what they said without judgment, even if
their opinion was of minor importance. Women also
appreciated the presence and support of a midwife,
who provided a sense of security [22]. It has previously
been shown that women have been mistreated inchildbirth through physical abuse, not being asked fortheir consent to the care given, and being verbally

8

I. HILDINGSSON AND M. JOHANSSON

abused, leading to decreased power and autonomy.
Therefore, it is of great importance for women to
receive adequate information for decision-making andto receive care involving dignity and respect, free fromcoercion [23].
In the present study, parous women reported moreinternal factors, such as helplessness, powerlessness,inability to give birth, and uncertainty, than nulliparous women. Previous traumatic birth experiences
have previously been related to fear of birth in parous
women [1,10,24], including feelings of helplessness[10] and uncertainty [1,22]. Women with a fear of birthviewed it as a time of uncertainty where they lackcontrol and the midwife in control the birth [1].
Interactions with health care providers have a significant impact on women’s experiences of birth [24], andthe medicalization of childbirth may sustain dependency on and confidence in interventions. Having atrusting relationship with a midwife, along with individualized women-centered models of care that support physiological childbirth, have the potential tostrengthen women’s self-efficacy [10,21,24]. Midwife
counseling has also helped women with fear of birthin coping with the uncertainty of childbirth, by providing a sense of security [1].
In the current study, the baby’s health andwell-being were not reasons behind women’s fear ofbirth; most surprising was the lack of worry in nulliparous women about the baby being sick. This lack ofconcern for the baby’s health and well-being may beunderstood as a consequence of maternal confidence.
A concept analysis of 24 articles defined maternal confidence in physiological birth as a normal process,given the body’s innate ability to give birth. A trusting
relationship with the maternity care provider in anenvironment where women feel safe, receive information and trust the maternity system increases pregnant
women’s self-confidence in a physiological birth.
Increased feelings of confidence and autonomy, inturn, resulted in decreased fear of childbirth [25]. Not
all women have confidence in a physiological birth:previous experiences of fetal distress during childbirthand adverse neonatal outcomes have been related toexperiences of fear of birth [10].
In the current study, nulliparous women reported
fear related to partners not being allowed to participate during antenatal visits, while parous womenreported lower odds of support from their partner.
Data for the current study were collected during the
COVID-19 pandemic, which restricted the involvementof women’s partners during childbirth. According to asystematic review based on 58 scientific publications, asignificant COVID-19 restriction that affected parents’birth experience was the absence of support persons
during antenatal visits. Especially nulliparous womenand parous women with previous childbirth complications stressed a need for their partner to accompany
them during antenatal appointments and ultrasoundscans. Some women felt lonely, overwhelmed by information, stressed, vulnerable, anxious, fearful, and worried that they would be alone if an ultrasound scanwould show a fetal abnormality [26]. In addition, a
supportive partner and a long partnership can decreasenulliparous women’s fear of birth, whereas relationshipproblems may intensify severe fear of birth [10,27].
In the current study, no association was foundbetween severe fear of birth and blood and injection
phobias, but parous women reported fear of fainting
as a reason for their fear. Few studies address the fearof fainting in relation to fear of birth [28–30]. In a
Swedish interview study, women described themselves
as sensitive, fearful, and prone to fainting [29].
The cluster analysis in the current study showed different patterns of reasons and a kind of dose–response
relationship with severity. These findings highlight theimportance of investigating women’s reasons behind
their fear of birth. Women in the major complexity cluster group seem to be most vulnerable, representing
young and nulliparous women with high fear, lack ofsupport, previous and current mental health problems,and exposure to domestic violence. One way to support women in this cluster might be to offer continuity of midwifery care, such as caseload, as the best
available mode, as also described in a narrative systematic review by Cibralic et al. [31]. Characteristics ofwomen who prefer continuity of care have been
described in a longitudinal cohort study to be younger
women, nulliparous women and women with fear ofbirth [18].
Women in the relative major complexity clustergroup were most prone to report a variety of reasons
at moderate levels and had partner support. A lack ofpartner support has been shown to be related to fearof birth; in contrast, when women are able to discuss
their specific fears with their partner, they felt understood and taken seriously. Previously described in ameta-synthesis of qualitative research evidence womenin the perinatal period have felt empowered when
having a supportive partner [1].
This study is limited by its observational design, theself-selecting nature of the survey, and the fact thatwomen were recruited through hospitals and throughsocial media. No information about how many womennoticed the study information is available, which is alimitation. Another limitation is the under-representationof foreign-born women in the study sample, which

Journal of Psychosomatic Obstetrics & Gynecology

reduces its capacity to be generalized to wider populations of women. Using two types of measures of fearof birth might have had an impact on the findings,
and the dichotomization of the Likert scale. The choiceof comparing women who assessed fear ‘to a verylarge extent’ with ‘less than a very large extent’ aimed
to identify women with strong or severe fear and theirreasons for fear of birth. Another possible choice
would have been to collapse ‘a very large extent’ and‘a large extent’. When using ‘a very large extent’ 95%
were classified as having FOBS 60 or more. Classifying
fear of birth by using only the two questions of the
FOBS might limit the prevalence of fear; however, theFOBS is a validated instrument that has been used inmany studies and is a valuable screening instrument inclinical practice in Sweden and in other countries. The
present study shows that women’s self-assessment isfairly similar to the measure with FOBS. Combining
FOBS as a screening tool together with discussion withwomen about their fear of birth and the reasons
behind might be a useful way to communicate andmeasure fear of birth. The strength of this study was
the large sample size that strengthens the validity of
the findings, and the results of women’s reported reasons behind their fear of birth concurs with those seenin previous studies.

Conclusion
Women with fear of birth have various reasons anddiverse complexities underpinning their fears, and heterogeneity more or less prevails among fearful women.
Healthcare providers need to investigate these reasons
further and support pregnant women with childbirthfear in line with their needs and parity status.
Interventions to develop the best evidence-based support for expectant parents according to individual
needs are crucial.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
The author(s) reported there is no funding associated withthe work featured in this article.

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