Is it Necessary to Evaluate Fear of Childbirth in Pregnant Women? A Scoping Review

Objective  To review concepts, definitions, and findings about fear of childbirth (FOC). Methods  A bibliographic review was carried out through the main scientific databases in 2020. Results  All 32 articles considered potentially relevant were analyzed. A recent study suggests that the global prevalence of FOC can reach up to 14%. Factors such as parity, gestational age, previous birth experience, age and nationality of the woman seem to influence FOC. Conclusion  Fear of childbirth could be related to an increased risk of adverse obstetric outcomes such as maternal request for cesarean delivery, preterm birth, prolonged labor, postpartum depression, and post-traumatic stress. These evidence highlight the importance of the discussion regarding this topic.


Introduction
The expression "fear of childbirth" (FOC) could have a substantial impact on the choice of delivery mode and, therefore, on maternal-fetal outcomes. Fear is a primary and basic emotion within a spectrum that comprises concerns, varying in intensity from mild and strong fear to phobia. 1 There is no consensus in the literature regarding the definition of FOC. This is a broad concept, and it is used to describe the types of anxiety and fears experienced by women regarding pregnancy and childbirth. 2 Within this context, there are different denominations used, and there is no standardization of appropriate assessment tools of FOC. 3 Thus, FOC represents an extensive area for research, with many gaps regarding multiple aspects of this topic still needing to be filled. 2 Thus, the aim of the present review is to review concepts, definitions, and findings about FOC, to contextualize the importance of its discussion during prenatal care, and, therefore, contextualize the importance of its discussion during prenatal care.

Methods
The topic of FOC has many gaps, from its definition to its diagnosis and evaluation. Due to the relevance of this theme in clinical practice, a narrative review was carried out to bring up some central aspects on this subject and, thus, encourage the investigation of FOC during prenatal care. Therefore, a comprehensive bibliographic review was carried out through an electronic search dating from January 2000 up to December 2020, based on the recommendations set out in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, in the following databases: PubMed, MEDLINE, Cochrane Library, LILACS, and SciELO. The search was made regarding the definition of TOC and its evaluation using the following search terms: pregnant women AND/OR pregnancy AND fear of birth AND/OR fear of childbirth, based on Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH). The search was initially restricted to studies published in Portuguese or English, performed on humans, review articles (systematic review and/or meta-analysis), clinical trials (randomized or not), and clinical protocols. When no clinical trials were found for the topic sought, the search for observational studies was included.

Results
The searches yielded 1,024 articles, 302 of which were excluded because they were duplicates in the databases. A total of 572 articles were excluded after the analysis of the titles and abstracts, and 44 were excluded after full text analysis because they failed to meet the study objectives. After the first evaluation, 31 full texts of articles considered potentially relevant were retrieved and analyzed in detail (►Figure 1).
The reference lists of all full articles retrieved were analyzed to identify other potentially relevant articles from the title. The main findings are reported in the discussion session (►Table 1).

Severe Fear of Childbirth (Tokophobia)
Severe FOC is called tokophobia and is classified within the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).  In this situation, FOC gains such a proportion that it will negatively impact the health of a woman, 4,5 turning into a disabling factor that interferes with occupational and domestic functions, as well as with social activities and relationships. 2 Tokophobia is also referred to as an "unreasoning dread of childbirth"; however, no consensus about the definition exists. Many of the articles published so far refer to tokophobia as a severe FOC rather than an irrational dread of childbirth. [6][7][8] Tokophobia is categorized into two forms: primary and secondary. 1,10 Primary tokophobia affects nulliparous women and is the FOC proper. It may result from fears that emerged during adolescence or at the beginning of adulthood, or from stories of experiences told by close persons, or is related to an anxiety disorder. In contrast, secondary tokophobia is the FOC related to a previous birth experience that was negative or traumatic. 2

Prevalence of Fear of Childbirth
Pregnancy and birth are marked by concerns and fears, observed in up to 80% of habitual-risk pregnant women. 10 There are divergences in the prevalence of FOC and tokophobia between studies, which are mainly due to the lack of consensus regarding the definition of this disease and the variety of assessment instruments used. [11][12][13] A recent study suggested that the global prevalence of FOC can reach 14%, 4 while other studies report a prevalence of 6 to 10%. 14-16

Characteristics of Women with Fear of Childbirth
Nulliparous women are more afraid of childbirth than multiparous women, both in early and in late pregnancy. Furthermore, a more advanced gestational age is associated with a higher level of FOC. A Finnish study involving a sample of 1,400 women demonstrated that pregnant women with < 20 weeks of gestation had lower scores of FOC compared with those with more advanced gestational ages, and this difference was more significant in multiparous than in nulliparous women. 11 Fear of childbirth in women who had 1 previous caesarean section is higher ( 11 In a study including Swedish and Australian women, participants with a previous cesarean section reported a negative experience and a higher prevalence of FOC more often than those with a previous vaginal delivery. 17 In addition to parity, gestational age, and previous birth experience, the age and nationality of the woman also seem to influence the FOC. Ternström et al. 19 describe that women < 25 years old had greater FOC than women > 35 years old. The authors also observed greater FOC in foreigners when compared with women born in Sweden.

Signs and Symptoms
The physiological manifestations of fear include sleep disorders, 19,20 nightmares, 2,5 tachycardia, tension, restlessness, nervousness, and stomach pain. 20 These physiological responses generally interact with cognitive and behavioral aspects, generating anxiety as a response. Examples of cognitive components are automatic negative thoughts 21 , negative expectations and beliefs about yourself, the world, and the future, 22 and specific attention disorders caused by threatening stimuli or situations. 23,34 Regarding behavioral components, the individual starts to avoid situations that are unpleasant and threatening. 1

• Fear of childbirth domains
Fear of childbirth in women comprises four domains: 1. Infant wellbeing. 2. The labor process ranging from pain, medical interventions, and abnormal evolution of labor to maternal/fetal death.
3. Personal conditions such as loss of control and distrust of the ability to give birth. 4. External conditions, especially interaction with the team. 26 Catastrophizing, defined as the tendency to exaggerate the possible negative aspects of pain, 22,24 and the intolerance of uncertainty about childbirth outcomes are considered the most relevant predictors of FOC. 3 Several factors can influence the development of fear of childbirth, including biological factors such as infertility, fear of pain, fear for the wellbeing of the infant, social factors involving the support and environment of the woman, psychological factors related to changes determined by maternity, and factors secondary to previous experiences of the woman and reports of persons close to her (►Figure 2). 25 • Fear acquisition and learning Psychological factors may contribute more strongly to the emergence of FOC and anxiety than demographic and obstetric factors or obstetric history. 3 Fear is acquired through three pathways. 24 1. Conditioningwhen the association that was learned happens. Example: being in a hospital or thinking about childbirth (object or situation) is associated with discomfort (aversive situation). 2. Indirect exposurewatching someone's delivery.
3. Indirect exposure through informationreports of another women's delivery. Indirect exposure and negative experiences can lead to fear acquisition. On the other hand, contact with reports of positive birth experiences can reduce fear. 35 • Anxiety and depression during pregnancy Fear of childbirth during pregnancy has been associated with anxiety, depression, and stress. 36 42 These factors are also cited in studies conducted in other countries. 29,43 Since the rates of preference for cesarean delivery in Brazil exceed those reported in other countries, social, economic, and cultural factors may also be related to the choice of delivery mode. Women with private health insurance seem to express more frequently their desire for childbirth, while women using the SUS often do not have this possibility. 44 Another factor that contributes to the high preference for surgical delivery in Brazil is the lack of information of pregnant women about delivery routes so that they can understand the risks and benefits of cesarean and vaginal delivery. 45 It is possible that the diagnosis of tokophobia is the primary cause for requesting cesarean delivery. 5,46 Women who report high levels of FOC are more likely to request a cesarean delivery. 12,47,48 Størksen et al. 30 showed a strong association between FOC and preference for elective cesarean section (OR ¼ 4.6; 95%CI: 2.9-7.3). Situations in which this fear is not treated in a timely manner can increase the chance of a cesarean delivery by up to 5.2 times, 41 and thus lead to a cesarean section without medical indication and exposure of the patient to unnecessary risks. 11,30 Severe FOC may be related directly to an elective or emergency cesarean section in cases of cesarean delivery on request, 30 or indirectly in cases of an increase in uterine contractility and risk of fetal hypoxia triggered by high levels of adrenaline and norepinephrine resulting from exacerbated fear and anxiety. 49

• Postpartum depression and post-traumatic stress
Postpartum depression is recognized worldwide as a health condition that can affect between 10 and 15% of women. 31 Furthermore, some pregnancy factors have been associated with the development of post-traumatic stress, especially depression during pregnancy (r ¼ 0.51) and FOC (r ¼ 0.41). 32 After compiling all this information, we can have an overview of FOC and its implications. The strength of our review is its comprehensive scope, including all major types of clinical investigations, and its thorough search strategy. Also, it brings to light an important topic and the different aspects of its evaluation, since it describes possible influences in fear of childbirth.
Our scoping review has some limitations. First, there is limited literature about this topic, and this leads to less data to review and evaluate. Also, we did not access the quality of the selected articles, since we had a limited number of studies selected. Fear of childbirth is related to an increased risk of adverse obstetric outcomes such as maternal request for cesarean delivery, preterm birth, prolonged labor, postpartum depression, and post-traumatic stress. These evidence highlight the importance of the discussion about FOC on prenatal care and light up an alert for the necessity of strategies for the evaluation and treatment of FOC in the future.