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A prospective study of effects of psychological factors and sleep on obstetric interventions, mode of… Hall, Wendy A; Stoll, Kathrin; Hutton, Eileen K; Brown, Helen Aug 3, 2012

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RESEARCH ARTICLE Open AccessA prospective study of effects of psychologicalfactors and sleep on obstetric interventions,mode of birth, and neonatal outcomes amonglow-risk British Columbian womenWendy A Hall1*, Kathrin Stoll2, Eileen K Hutton3 and Helen Brown1AbstractBackground: Obstetrical interventions, including caesarean sections, are increasing in Canada. Canadian women’spsychological states, fatigue, and sleep have not been examined prospectively for contributions to obstetricinterventions and adverse neonatal outcomes.Context and purpose of the study: The prospective study was conducted in British Columbia (BC), Canada with650 low-risk pregnant women. Of those women, 624 were included in this study. Women were recruited throughproviders’ offices, media, posters, and pregnancy fairs. We examined associations between pregnant women’sfatigue, sleep deprivation, and psychological states (anxiety and childbirth fear) and women’s exposure toobstetrical interventions and adverse neonatal outcomes (preterm, admission to NICU, low APGARS, and lowbirth weight).Methods: Data from our cross-sectional survey were linked, using women’s personal health numbers, to birthoutcomes from the Perinatal Services BC database. After stratifying for parity, we used Pearson’s Chi-square toexamine associations between psychological states, fatigue, sleep deprivation and maternal characteristics. We usedhierarchical logistic regression modeling to test 9 hypotheses comparing women with high and low childbirth fearand anxiety on likelihood of having epidural anaesthetic, a caesarean section (stratified for parity), assisted vaginaldelivery, and adverse neonatal outcomes and women with and without sleep deprivation and high levels of fatigueon likelihood of giving birth by caesarean section, while controlling for maternal, obstetrical (e.g., infantmacrosomia), and psychological variables.Results: Significantly higher proportions of multiparas, reporting difficult and upsetting labours and births,expectations of childbirth interventions, and health stressors, reported high levels of childbirth fear. Women whoreported antenatal relationship, housing, financial, and health stressors and multiparas reporting low family incomeswere significantly more likely to report high anxiety levels. The hypothesis that high childbirth fear significantlyincreased the risk of using epidural anaesthesia was supported.Conclusions: Controlling for some psychological states and sleep quality while examining other contributors tooutcomes decreases the likelihood of linking childbirth fear anxiety, sleep deprivation, and fatigue to increasedodds of caesarean section. Ameliorating women’s childbirth fear to reduce their exposure to epidural anaesthesiacan occur through developing effective interventions. These include helping multiparous women process previousexperiences of difficult and upsetting labour and birth.Keywords: Childbirth fear, Sleep deprivation, Fatigue, Anxiety, Obstetrical interventions, Neonatal outcomes* Correspondence: Wendy.hall@nursing.ubc.ca1University of British Columbia School of Nursing, T201, 2211 Westbrook Mall,Vancouver, British Columbia, Canada V6T 2B5Full list of author information is available at the end of the article© 2012 Hall et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Hall et al. BMC Pregnancy and Childbirth 2012, 12:78http://www.biomedcentral.com/1471-2393/12/78BackgroundBirthing women in British Columbia (BC) have one ofthe highest rates of obstetrical intervention in Canada.Of 44,508 women giving birth in 2010 in BC [1], 22%had primary caesarean sections; among women havingvaginal birth, 30% had epidural anaesthesia [2], an inter-vention that has been associated with increased risk fornegative effects on breastfeeding initiation [3,4] and dur-ation [5]. With a caesarean section rate at almost doublethe 15% rate recommended by the World HealthOrganization [6], health care professionals are alarmedat the rates of caesarean sections and other childbirthinterventions in British Columbia [7,8]. Caesarean sectionspose increased physical risks for mothers and infants,including extended hospital stays and readmissions [9-12].Investigations have focused on contributions ofhealth care practices and health care providers to ob-stetrical interventions [7,8,13]. Empirical data fromother countries has supported contributions of women’spsychological status to obstetric interventions [14-22].Canadian studies have examined contributions of healthcare practices to labour and birth interventions; however,none have explored independent effects of specificpsychological states, e.g. childbirth fear, on interventionsand outcomes, while controlling for other psychologicalstates, e.g. anxiety.Previous WorkThis study builds on previous work, where we exploredmeasures of childbirth fear, sleep deprivation, fatigue,and anxiety and their relationships in a sample of preg-nant British Columbian women [23]. In a cross-sectionalstudy, we obtained data from 650 women. Using postersin providers’ offices and gathering places, media, andpregnancy and baby fairs, we recruited women fromcommunities across British Columbia (BC) with 150births or more annually. Eligibility criteria included:pregnant women who resided in BC, could read andspeak English, and were between 35 and 39 weeks gesta-tion, with no medical complications during pregnancy(e.g. bleeding, pregnancy-induced hypertension, gesta-tional diabetes). Of those women, 25% reported highlevels of childbirth fear and 22% reported sleepdeprivation (< 6 hours of sleep per night). Childbirthfear, fatigue, sleep deprivation and anxiety were highlycorrelated. For example, women with high childbirthfear were more likely to report higher levels of anxietyand fatigue, less sleep hours per night, more daily stres-sors, and less available help. Higher family income, afirst time pregnancy, completed university education,and higher levels of anxiety and fatigue were associatedwith higher childbirth fear scores, explaining 29% of thevariance. The relationships between childbirth fear, fa-tigue, sleep deprivation, and anxiety raised questionsabout their potential contributions to obstetrical andneonatal outcomes.Psychological States in Pregnancy: Prenatal Anxiety andChildbirth FearIn a review of 60 studies examining prenatal maternalstress as a composite measure (including state anxiety),Beydoun and Saftlas concluded maternal prenatal stressand infants’ low birth weights (<2500 grams) were posi-tively correlated [24]. For American women, prenatal anx-iety has had a strong association with shortened length ofgestation, [25], epidural analgesia, unplanned caesareansection [26]; and preterm birth [27] For Swedish mothers,depression/anxiety was positively associated with risk forplanned caesarean section and increased length of labour[28]. Fear of childbirth has been associated with requestsfor elective caesarean deliveries [14,16,18-20,22] andemergency caesarean section, after controlling for obstet-rical complications and history of previous caesarean sec-tions [21] but nulliparous and multiparous women havereported differences in childbirth fear [18,29]. For 443British women, neither fear of childbirth nor anxiety wasassociated with mode of birth, including emergency orelective caesarean births [30]. Studies have examinedchildbirth fear and, and in some instances anxiety, withouttaking fatigue and sleep deprivation into account.Prenatal Sleep Deprivation & FatigueGiven the many sleep disruptions (e.g., fetal movement,heartburn, voiding at night) that occur in late pregnancy, itis not surprising some pregnant women experience high fa-tigue levels [15,31] or reductions in sleep time [31,32]. InTaiwanese, Swedish, and American samples, fatigue andsleep deprivation have been associated with increased riskof caesarean sections [15,17,33]. American women report-ing less total sleep time experienced higher levels of labourpain and more fatigue during labour [34]. Chang and col-leagues concluded sleep deprivation is linked to higherlevels of pro-inflammatory serum cytokines, which in turnare associated with a higher prevalence of preterm deliveryand postpartum depression [35]. Despite these contribu-tions about effects of sleep deprivation on obstetrical out-comes, previous studies have not examined whether fatigueand sleep deprivation contribute to requests for analgesiaand obstetrical interventions beyond caesarean sections.The purpose of the study is to examine prospectivelyassociations between British Columbian women’s fatigue,sleep deprivation, psychological states (anxiety, childbirthfear), and characteristics (e.g. age and stressors) and theirexposure to obstetrical interventions (induction, augmen-tation, epidurals, and any anaesthetic, caesarean section,assisted vaginal delivery), and adverse neonatal outcomes(preterm, admission to NICU, low APGARS, and lowbirth weight).Hall et al. BMC Pregnancy and Childbirth 2012, 12:78 Page 2 of 10http://www.biomedcentral.com/1471-2393/12/78MethodThis study uses the data from our prior work [23] andlinks it to maternal and newborn birth outcomes. Wesought access to maternal and newborn data from Peri-natal Services BC (PSBC), which maintains a provincialdatabase of all maternal obstetric and newborn out-comes. Using the personal health numbers of the 97% ofwomen enrolled in our prior study who had consentedto have their maternal and newborn records linked totheir survey data, we were able to examine relationshipsbetween women’s childbirth fear, anxiety, sleepdeprivation, fatigue and obstetric interventions, mode ofbirth, and newborn outcomes. Our hypotheses to betested by logistic regression analysis were developed apriori, based on the literature. Because childbirth feardiffers by women’s parity [29], we divided the sample byparity equal 0 and ≥1 to test hypothesis 3. The wholesample was used to test the remaining hypotheses whichfollow:1) women with high levels of childbirth fear are morelikely to have epidural anaesthetic (controlling formaternal age, parity, infant macrosomia, previouscaesarean deliveries, fatigue, anxiety, sleepdeprivation, and available support) than those withlow/moderate childbirth fear;2) women with high levels of anxiety are more likely tohave epidural anaesthetic (controlling for maternalage, parity, infant macrosomia, previous caesareandeliveries, fatigue, fear of birth, sleep deprivation,and available support) compared to those withlow/moderate childbirth anxiety;3) a) nulliparous women with high childbirth fear aremore likely to give birth by caesarean section(controlling for maternal age, infant macrosomia,intent to request caesarean section, fatigue, anxiety,sleep deprivation, and available support) thanwomen with low/moderate childbirth fear; b)multiparous women with high childbirth fearare more likely to give birth by caesarean section(controlling for maternal age, infant macrosomia,previous caesarean deliveries, fatigue, anxiety,history of difficult or upsetting labours andbirths, sleep deprivation, and available support)than women with low/moderate childbirth fear;4) women with sleep deprivation (< 6 hours per night)are more likely to give birth by caesarean section(controlling for maternal age, infant macrosomia,previous caesarean deliveries, intent to requestcaesarean section, anxiety, childbirth fear, andavailable support) compared to women withoutsleep deprivation;5) women with high levels of fatigue are more likelyto give birth by caesarean section (controlling formaternal age, infant macrosomia intent to requestcaesarean section, previous caesarean sections,childbirth fear, anxiety, and available support) thanwomen with low fatigue levels;6) women with high levels of childbirth fear will bemore likely to have an assisted vaginal delivery(controlling for maternal age, infant macrosomia,fatigue, anxiety, sleep deprivation, and availablesupport) compared to women with moderate/lowlevels of fear;7) women with high levels of anxiety will be morelikely to have an assisted vaginal delivery (controllingfor maternal age, infant macrosomia, fatigue, fear ofbirth, sleep deprivation, and available support) thanwomen with moderate/low levels of anxiety;8) women with high fear of birth will be more likely toexperience adverse neonatal outcomes (controllingfor maternal age, fatigue, anxiety, sleep deprivation,and available support) compared to women withmoderate/low levels of fear; and9) women with high levels of anxiety will be morelikely to experience adverse neonatal outcomes(controlling for maternal age, fatigue, fear of birth,sleep deprivation, and available support) thanwomen with moderate/low levels of anxiety.ProceduresThe study was reviewed and approved by the Universityof British Columbia Behavioural Ethics Review Board(H05-81091) and BC Women’s and Children’s HospitalEthics Committee (W06-0211). Signed consent formsaccompanied completed questionnaires. The research isin compliance with the Helsinki Declaration. In the pre-vious study, we enrolled 650 pregnant women between35–39 weeks gestation from May 2005 to July 2007 (See23 for details). For the analysis of obstetrical outcomes,we excluded women who produced twins (n =10 sets),whose data could not be matched to birth records bypersonal health number (n = 5), and who did not consentto have their birth records linked to the survey data(n = 11) for a total of 624 participants. Women who didnot consent to have their birth records linked to surveydata did not demonstrate significant differences on anydemographic characteristics than women who consented.MeasuresWe collected data about maternal characteristics includ-ing: maternal age, relationship status, self-identified eth-nicity, education level, family income, number and typeof daily stressors, previous adverse labour and birthexperiences, type of primary care provider, attendance atchildbirth education classes, and intentions regardingcesarean birth or other interventions. Respondents alsocompleted measures for childbirth fear, anxiety, fatigue,Hall et al. BMC Pregnancy and Childbirth 2012, 12:78 Page 3 of 10http://www.biomedcentral.com/1471-2393/12/78and sleep quality. From the PSBC birth records data, weobtained data on the following variables: women’s parity,epidural anaesthesia, any type of anaesthesia, instrumen-tal delivery (forceps and vacuum extraction), any type ofcaesarean birth (emergent, scheduled), preterm births ofless than 37 weeks, infant macrosomia, infant gestationat birth, APGAR scores at 1 and 5 minutes post birth,infant prematurity (< 37 weeks), infant low birth weight,and admissions to levels 2 and 3 neonatal intensive carenurseries. Level 2 and 3 nurseries provide ventilator sup-port for high risk infants.For the survey, we used the 33 item Wijma DeliveryExpectancy/Experience Questionnaire-A (W-DEQ) tomeasure women’s fear of childbirth [36]. Pregnantwomen rated their expectations about experiences dur-ing labour and birth on scale from 1–5. Scores rangefrom 0–165; higher scores indicate increased levels ofchildbirth fear. We categorized women as belonging inthe high fear group if they scored 66 or higher on theW-DEQ, as reported by Zar et al. [37]. The W-DEQ hasdemonstrated reliability for nulliparous and multiparouswomen [36].To measure anxiety, we used Spielberger’s State Anx-iety Inventory (SAI), a 20 item measure of current feel-ings of anxiety [38]. Scores range from 20–80. This toolhas demonstrated validity and reliability with the child-bearing population [30,39]. Similarly to other investiga-tors [40], we labeled women as having high anxiety ifthey scored above 40 on the scale.Mindell’s sleep questionnaire assessed the pregnantwomen’s sleep patterns and disruptions; it provides simi-lar data to sleep diaries [31]. Women with less than 6hours of sleep have been categorized as sleep deprived[17]; we also characterized women as sleep deprived ifthey slept less than 6 hours per night (on average, over atwo week period).The Multidimensional Assessment of Fatigue Scale(MAF) is a 16 item instrument that assesses fatigue [41].We used the Global Fatigue Index which omits thechange in fatigue item. Higher scores indicate more fatigue.The MAF has demonstrated reliability and constructvalidity with pregnant women [42].Data AnalysisUsing Pearson’s Chi-square test, we examined differ-ences in proportions of women by characteristicsreported antenatally for high childbirth fear and anxietylevels compared with low/moderate levels and womenwith and without sleep deprivation, separately for nulli-paras and multiparas.We performed hierarchical logistic regression model-ing to test the 9 hypotheses outlined previously. Controlvariables were entered in step 1 of the model, followedby the psychosocial predictor of interest (step 2). Weused the Nagelkerke statistic and associated p value todetermine whether the addition of the predictor vari-ables increased the explanatory power of the models[43]. We calculated 95% confidence intervals around theresulting odds ratios (OR). The reference groups werewomen with low anxiety and low/moderate fear andmore than 6 hours of sleep per night. For the dichotom-ous variable to assess newborn adverse outcome, neo-nates received a value of 1 if they had any one or all ofthe following: admission to an NICU level 2 or 3, 5 mi-nute APGAR score < 7, birth weight < 2500 g or gesta-tional age < 37 weeks.Assuming medium effect sizes and alpha = .05, a sam-ple size of 618 provided excellent power (in excess of.95) for all analyses. For the regression analyses examin-ing women’s outcomes, we used Bonferroni’s correction(divided 0.05 by 7 hypotheses) to accept p < 0.007. Weused p < 0.01 as an indicator of significant results for theChi Square analyses to avoid making a type 1 error dueto multiple comparisons. For scales with less than 10%missing data, values were imputed by replacing eachvalue with the mean of observed values for the variable.ResultsWe examined associations between levels of childbirthfear and anxiety, fatigue, sleep deprivation, and maternalcharacteristics. For our sample of pregnant women,Cronbach’s alphas for the standardized measures rangedfrom 0.92 – 0.93 [23]. We found women in the highchildbirth fear group did not differ significantly fromwomen in the low/moderate fear group in terms of age,income, most stressors, educational attainment, loneparent status, ethnicity, and attendance at childbirthclasses (all p > .01, See Table 1). More multiparas in thehigh fear group reported experiencing health as a stres-sor (χ² = 16.564, df =12, p < 0.001) and using obstetri-cians as care providers compared to multiparas in thereference group (χ² = 19.45, df= 2, p < 0.001).A significantly higher proportion of multiparas with ahistory of difficult and upsetting labour and birthreported high levels of childbirth fear (χ² = 10.827, df= 1,p= 0.001; χ² = 23.286, df= 1, p < 0.001). Higher propor-tions of multiparas expecting to have obstetric interven-tions during labour and birth (χ² = 16.767, df= 1.p < 0.001) also reported high levels of childbirth fear.Women with high childbirth fear did not request a caesar-ean section more often than women with low/moderatechildbirth fear (see Table 1).Significantly fewer multiparas over the age of 35(χ² = 14.31, df= 1, p < 0.001) reported high levels of anx-iety compared with multiparas who were younger. Sig-nificantly more multiparas with a family income belowthe provincial average ($ 60,000; χ² = 6.44, df= 1,p= 0.01) reported high anxiety levels compared withHall et al. BMC Pregnancy and Childbirth 2012, 12:78 Page 4 of 10http://www.biomedcentral.com/1471-2393/12/78those who had incomes above the provincial average.Compared to women reporting low anxiety, larger pro-portions of nulliparas and multiparas with high anxietyreported stressors (See Table 2). Sleep deprivation wasassociated with health-related stressors among nulli-paras, but not multiparas (χ² = 22.054, df= 1, p < 0.001).Hypothesis TestingWe report on the findings for each hypothesis by num-ber. Hypothesis 1: High fear of childbirth significantlyincreased the odds of having an epidural (OR= 2.02; 95%CI: 1.26-3.22; p= 0.003) controlling for maternal age,parity, infant macrosomia, previous cesarean section, fa-tigue, anxiety, sleep deprivation and available support(see Table 3). Adding fear of childbirth in the secondstep of the logistic regression model increased theNagelkerke R2 from 0.17 to 0.19. In other words, addingfear of birth accounted for an addition 2% of the vari-ance explained by the model.Hypothesis 2: High anxiety was not a significant pre-dictor of having an epidural (OR= 0.92; 95% CI: 0.56-1.50; p= 0.725) when controlling for parity, infantmacrosomia, previous cesarean section, fatigue, fear ofbirth, sleep deprivation, and available support.Hypothesis 3a: Fear of birth was not a significant pre-dictor of caesarean section among nulliparas (OR= 1.58;95% CI: 0.52-4.83; p= 0.421) when controlling for mater-nal age over 35, infant macrosomia, intent to requestTable 1 Comparison of women with low and high childbirth fear on characteristics by parity (N=624)NULLIPARAS MULTIPARASLow/moderate fear(N= 278)High fear(N= 93)Low/moderate fear(N= 187)High fear(N) = 65)% (N) % (N) p % (N) % (N) pMaternal characteristicsAge> 35 13.3 (37) 16.1 (15) 0.498 31.6 (59) 29.2 (19) 0.727Family Income< $ BC Average 26.6 (74) 21.5 (20) 0.326 37.4 (70) 32.3 (21) 0.459EducationNo university 44.2 (123) 46.2 (43) 0.738 48.7 (91) 52.3 (34) 0.613University degree 55.8 (155) 53.8 (50) 51.3 (96) 47.7 (31)Lone parent 2.2 (6) 1.1 (1) 0.506 2.1 (4) 0 (0) 0.235EthnicityAboriginal 1.5 (4) 2.2 (2) 0.065 1.7 (3) 5.0 (3) 0.363Caucasian 91.6 (241) 83.0 (73) 90.3 (159) 88.3 (53)Asian 6.9 (18) 14.8 (13) 8.0 (14) 6.7 (4)Maternity care providerMidwife 24.8 (69) 20.4 (19) 0.069 32.1 (60) 10.8 (7) < 0.001Family physician 44.2 (123) 35.5 (33) 38.0 (71) 30.7 (20)Obstetrician 31.0 (86) 44.1 (41) 29.9 (56) 58.5 (38)Attended childbirth classes 83.1 (231) 84.9 (79) 0.676 12.8 (24) 12.3 (8) 0.999History of difficult labour and birth NA NA NA 46.5 (86) 70.3 (45) 0.001History of upsetting labour and birth NA NA NA 28.6 (53) 62.5 (40) < 0.001Maternal characteristicsSource of stressor - relationships 23.0 (64) 32.3 (30) 0.076 47.3 (88) 60.9 (39) 0.060Source of stressor – finances 48.6 (135) 51.6 (48) 0.610 47.8 (89) 62.5 (40) 0.043Source of stressor – housing 18.0 (59) 24.7 (23) 0.157 14.5 (27) 28.1 (18) 0.015Source of stressor – employment 26.3 (73) 38.7 (36) 0.023 20.4 (38) 32.8 (21) 0.044Source of stressor – education 7.9 (22) 2.2 (2) 0.050 4.8 (9) 9.4 (6) 0.187Source of stressor – health 22.3 (62) 35.5 (33) 0.012 18.3 (34) 43.8 (28) < 0.001Requesting a caesarean section 1.1 (3) 3.2 (3) 0.155 11.3 (21) 16.9 (11) 0.241Requesting a caesarean section, excludingwomen with a previous caesarean section1.1 (3) 3.2 (3) 0.155 1.4 (2) 2.5 (1) 0.641Expecting obstetric interventions, excludingwomen with a previous caesarean section14.1 (39) 18.5 (17) 0.308 7.2 (10) 30.0 (12) < 0.001Hall et al. BMC Pregnancy and Childbirth 2012, 12:78 Page 5 of 10http://www.biomedcentral.com/1471-2393/12/78caesarean section, fatigue, anxiety, sleep deprivation, andavailable support.Hypothesis 3b: When controlling for maternal age, in-fant macrosomia, previous caesarean section, history ofdifficult or upsetting labours and births, fatigue, anxiety,sleep deprivation, and available support fear of birth wasnot a significant predictor of caesarean section amongmultiparas (OR= 1.58; 95% CI: 0.52-4.83; p= 0.421).Hypothesis 4: Sleep deprivation was not a significantpredictor of caesarean section (OR= 1.16; 95% CI: 0.72-1.88; p= 0.540) when controlling for maternal age, infantmacrosomia, intent to request caesarean section, previ-ous caesarean sections, childbirth fear, anxiety, and avail-able support.Hypothesis 5: When controlling for maternal age, in-fant macrosomia, intent to request caesarean section,previous caesarean sections, childbirth fear, anxiety,sleep deprivation, and available support fatigue was notan independent significant predictor of caesarean section(OR= 0.98; 95% CI: 0.96-1.00; p= 0.154).Hypothesis 6: Childbirth fear was not a significant pre-dictor of assisted vaginal delivery (OR= 1.10; 0.56-2.17;p= 0.785) when controlling for maternal age, infantmacrosomia, fatigue, anxiety, sleep deprivation, andavailable support.Hypothesis 7: Anxiety was not a significant predictorof assisted vaginal delivery (OR = 1.16; 0.57-2.34;p= 0.686) when controlling for maternal age, infantTable 2 Comparison of women with low and high anxiety on characteristics by parity (N= 624)NULLIPARAS MULTIPARASLow anxiety High anxiety Low anxiety High anxiety(N= 279) (N= 93) (N= 164) (N= 88)% (N) % (N) p % (N) % (N) pMaternal characteristicsAge> 35 15.1 (42) 11.8 (11) 0.441 39.0 (64) 15.9 (14) < 0.001Family Income< $ BC Average 24.4 (68) 28.0 (26) 0.491 30.5 (50) 46.6 (41) 0.010EducationNo university 42.7 (119) 50.5 (47) 0.185 44.5 (73) 59.1 (52) 0.027University degree 57.3 (160) 49.5 (46) 55.5 (91) 40.9 (36)Lone parent 1.8 (5) 2.2 (2) 0.826 1.8 (3) 1.1 (1) 0.675EthnicityAboriginal 1.1 (3) 3.4 (3) 0.343 1.3 (2) 5.1 (4) 0.218Caucasian 90.2 (239) 87.4 (76) 91.1 (143) 87.3 (69)Asian 8.7 (23) 9.2 (8) 7.6 (12) 7.6 (6)Maternity care providerMidwife 26.5 (74) 15.1 (14) 0.026 29.9 (49) 20.5 (18) 0.107GP 42.3 (118) 40.9 (38) 37.2 (61) 34.1 (30)Obstetrician 31.2 (87) 44.1 (41) 32.9 (54) 45.5 (40)Attended childbirth classes 83.5 (233) 83.9 (78) 0.936 12.2 (20) 13.6 (12) 0.743History of difficult labour NA NA NA 51.2 (83) 55.2 (48) 0.553History of upsetting labour NA NA NA 34.6 (56) 42.5 (37) 0.216Maternal characteristicsSource of stressor - relationships 21.1 (59) 37.6 (35) 0.002 42.3 (69) 66.7 (58) < 0.001Source of stressor – finances 45.2 (126) 61.3 (57) 0.007 43.6 (71) 66.7 (58) < 0.001Source of stressor – housing 15.1 (42) 33.3 (31) < 0.001 12.9 (21) 27.6 (24) 0.004Source of stressor – employment 26.2 (73) 38.7 (36) 0.021 17.8 (29) 34.5 (30) 0.003Source of stressor – education 5.4 (15) 9.7 (9) 0.144 3.7 (6) 10.3 (9) 0.035Source of stressor –health 20.8 (58) 39.8 (37) < 0.001 17.2 (28) 39.1 (34) < 0.001Requesting a caesarean section 1.1 (3) 3.2 (3) 0.154 9.2 (15) 19.3 (17) 0.022Requesting a caesarean section, excludingwomen with a previous caesarean section1.1 (3) 3.2 (3) 0.154 1.6 (2) 1.8 (1) 0.950Expecting obstetric interventions, excludingwomen with a previous caesarean section13.7 (38) 19.6 (18) 0.181 9.8 (12) 17.9 (10) 0.144Hall et al. BMC Pregnancy and Childbirth 2012, 12:78 Page 6 of 10http://www.biomedcentral.com/1471-2393/12/78macrosomia, fatigue, childbirth fear, sleep deprivation,and available support.Hypothesis 8: When controlling for maternal age, fa-tigue, anxiety, sleep deprivation, and available supportfear of birth was not a significant predictor of adverseneonatal outcomes (OR=1.16; 95% CI: 0.52-2.58;p= 0.714).Hypothesis 9: Anxiety was not a significant predictor ofadverse neonatal outcomes (OR=1.73; 95% CI: 0.76-3.92;p= 0.189) when controlling for maternal age, fatigue, fearof birth, sleep deprivation, and available support).DiscussionOur findings associating high fear of childbirth withmultiparas viewing health as a stressor are supported byLaursen and colleagues who found a population-basedcohort of nulliparous women with poor health weremore likely to report fear of childbirth [44]. The preva-lence of difficult and upsetting labours and births formultiparas with high childbirth fear reported in ourstudy has been supported by other studies. In a sampleof Chinese women who changed their preference to cae-sarean section for mode of birth, the largest proportionindicated fear of childbirth as their reason [45]. Of thosein Pang’s group preferring caesarean section for theirnext birth, 14% reported a hemorrhage, 5% reportedmanual removal of placenta, and 9% reported vaginal in-strumental birth during their previous births [45]. All ofthose events could contribute to women’s perceptions ofupsetting and difficult labours and births.Because significantly more multiparas in our high feargroup reported previous difficult labour and birthexperiences, it is not surprising that more of thosewomen selected obstetricians as care providers com-pared to multiparas in the reference group. Our findingssuggest those women anticipated more requirements forintervention in their births. Fisher and colleagues re-ferred to retrospective horror where women describednegative or difficult birth experiences inducing fear ofupcoming births [46]. More British mothers experien-cing a previous caesarean section or instrumental deliv-ery reported fear of future birth than those withuncomplicated vaginal deliveries [47]. The literature thatexamines Scandinavian women’s childbirth fear and pre-ference for caesarean section refutes our finding thathigh fear of birth was not significantly associated with arequest for a caesarean section [18,29]. It is possible thatthe W-DEQ was less culturally sensitive to Canadianwomen’s experience of childbirth fear than it has beenfor Scandinavian women. We also selected the cut-offscore for high fear (≥66), as suggested by Zar [37], butother researchers have used a cut-off score for severechildbirth fear (≥ 84) to predict risk for emergency cae-sarean section [21].Our finding that high childbirth fear predicted use ofepidural anaesthesia (EA) makes an important contribu-tion to the literature. Many women who are fearful ofbirth are particularly afraid of the pain of labour [48-50];however, there is not a clear link between fear of birthand pain relief during labour likely because pain relief isa complex matter. For 46 women surveyed 6 monthsafter vaginal birth, those who chose epidural anaesthesiawere more likely to report high fear of childbirth, an ex-ternal locus of control for childbirth, and passive compli-ance in the birth process [51]. Some studies conducted inScandinavia have reported fear during the first phase oflabour predicts total amount of pain relief during labourand increased likelihood of receiving epidural analgesia[52,53]; however, a study of 47 nulliparous women foundprenatal fear of childbirth was not associated with receiv-ing an epidural [54]. A recent Swedish study reportedwomen who were not successfully treated for childbirthfear were more likely to use epidurals for pain relief thanwomen with no reported fear of childbirth [55].Melender suggests caregivers ask women about theirfears, provide opportunities to discuss them, and pay spe-cial attention to primiparas and multiparas reportingnegative experiences of earlier pregnancies and births[56]. Psychosomatic support provided by caregivers canreduce women’s fear and concerns during pregnancy [22].For example, nurses and physicians can spend time withwomen shortly after their birth experiences to listen totheir birth stories and assist them to express any concernsor negative feelings. Having obstetrical caregivers providepsychosomatic support directly to women may strengthenwomen’s trust in the birth process and their care provi-ders more effectively than referral to counselling; a recentstudy that compared Swedish women referred to a unit totreat childbirth fear (cognitive-behavioural therapy andpsychoeducation) found the treated women experiencedTable 3 Hierarchical logistic regression model, testingpredictors of epidural anesthesiaBeta Wald SE p OR 95 % CIStep 1Age> 35 −0.048 0.038 0.249 0.846 0.953 0.585-1.553Multiparity −1.482 36.896 0.244 < 0.001 0.227 0.141-0.366Infant macrosomia 0.375 2.213 0.252 0.137 1.455 0.888-2.385Previous caesareansection−0.781 2.646 0.480 0.104 0.458 0.179-1.174Fatigue −0.017 2.271 0.011 0.132 0.984 0.963-1.005Sleep deprivation 0.262 1.224 0.237 0.269 1.300 0.817-2.070Support −0.036 0.633 0.045 0.426 0.965 0.884-1.053Step 2High fear 0.702 8.646 0.239 0.003 2.018 1.264-3.223High anxiety −0.089 0.124 0.254 0.725 0.915 0.556-1.504Hall et al. BMC Pregnancy and Childbirth 2012, 12:78 Page 7 of 10http://www.biomedcentral.com/1471-2393/12/78higher levels of obstetrical interventions (e.g., emergencycaesarean section and induction of labour) than womenin a reference group who did not report childbirth fear[57].The evidence for effects of epidurals on mode of deliv-ery is inconclusive. Epidurals have been associated withincreased risk for caesarean section in some studies [58-60] but, in others, they have protected nulliparas fromcaesarean deliveries [61]. Sharma and colleagues foundadvancing maternal age and epidural anaesthesiaincreased the risks of unplanned abdominal delivery fornulliparas [60]. In a prospective cohort study, Nguyenand colleagues reported epidural use was associated withtwice the risk for caesarean delivery for nulliparas andmultiparas [59]. Fenwick et al. failed to find an associ-ation between high childbirth fear and epidural anaes-thesia, after controlling for possible confounders in amultivariate model [58].Despite reports that fear of birth often leads to emer-gency caesarean section, studies of the effect of child-birth fear on mode of delivery have been inconclusive.Serious fear of childbirth (a score of 84 or higher on theW-DEQ) at 32 weeks gestation in a sample of 1981Swedish women tripled the risk of emergency caesareansection after excluding women with pregnancy compli-cations and other possible confounders from the analysis[21]. On the other hand, British women’s (n = 433) fearof birth and anxiety were not associated with subsequentemergency caesarean sections [30] and Australianwomen’s childbirth fear was not significantly associatedwith emergency caesarean section when controlling forobstetrical complications [58].Our study replicates findings that prenatal anxietydoes not have a significant effect on mode of deliveryand use of epidural anaesthetic in the first stage oflabour [62]. The lack of association between prenatalanxiety and increased risk for epidural analgesia in ourstudy is not in agreement with a study suggestingwomen with higher prenatal anxiety were more likely toreceive analgesia and those who received analgesia morelikely to have a surgical delivery [26] and a Swedishstudy that found worried women had significantlygreater odds of an emergency caesarean section [33].The lack of congruence might be explained by our useof state anxiety as a general measure of prenatal stresswhereas Saunders and colleagues included pregnancy-specific anxiety, prenatal life events, state anxiety, andperceived stress and the Swedish study used referencesin an electronic database to worried and worrying [33].Unlike other studies [15,17,33], our hypotheses aboutfatigue and sleep deprivation predicting increased riskfor caesarean section were not supported. We controlledfor many factors, including age, intent to request caesar-ean section, childbirth fear, and anxiety, whereas otherinvestigators controlled only for infant birth weight [17]or age, multiple gestation, history of preterm births, andabdominal operations during pregnancy [15] or age, dia-betes, gestational age, and epidural anaesthesia [33]. Thewomen in those studies may have intended to requestcaesarean section, which was not investigated. Accordingto Peterson, the reliability coefficients reported in ourstudy correspond with the minimally acceptable reliabil-ity levels for applied research, as suggested by Nunnally,specifically 0.90 or greater [63]. Peterson suggestedscales exhibiting very high alpha coefficients, e.g. 0.90 orhigher, may imply a high level of item redundancy ratherthan scale reliability and scales with higher alphas aregenerally self-administered rather than interviewer-administered [63].LimitationsThe study has a number of limitations. We did not use anobjective measure of maternal sleep hours. Collecting ob-jective actigraphic data about women’s sleep would havebeen very expensive and difficult to coordinate acrosslarge geographic distances. We sought no detail aboutwomen’s report of histories of difficult labour and births.We could have provided a short open-ended question toask women to describe the nature of their experiences.When we divided the sample into multiparas and nulli-paras to test our hypothesis about childbirth fear and cae-sarean birth we reduced the power to detect differences.The prevalence of adverse neonatal outcomes was verylow; despite combining the outcomes in a compositemeasure the prevalence of any adverse outcome was 6.3%.The low prevalence of adverse neonatal outcomesreflected the health of the study participants. In retrospect,we could have removed the hypotheses about adverse out-comes arising from childbirth fear and anxiety from thesuggested hypotheses because evidence was not as robustfor negative neonatal outcomes arising from these psycho-logical states. The study results are located in a Canadiancontext and are not generalizable to women in othercountries with very different obstetrical care patterns andhealth care systems.ConclusionOur results suggest attention be given to amelioratingwomen’s childbirth fear to reduce their exposure to epi-dural anaesthesia and to interventions for multiparouswomen to reduce childbirth fear arising from previousbirth experiences. Effective interventions to reducewomen’s exposure to caesarean section require particu-lar attention to sources of women’s childbirth fear, par-ticularly those women who have had experiences ofdifficult and upsetting labour and birth. Providing mul-tiparous women with opportunities to describe theirbirth experiences and receive support around processingHall et al. BMC Pregnancy and Childbirth 2012, 12:78 Page 8 of 10http://www.biomedcentral.com/1471-2393/12/78the events would be useful. Interventions to reducetrauma and fear arising from previous birth events couldbe evaluated through a randomized controlled trial.More prospective studies with large sample sizes from avariety of countries are required to explain how prenatalpsychological states and sleep contribute to obstetricalinterventions and potential adverse birth outcomes.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsWH was the principal investigator for the grant, designed and conceived thestudy, obtained statistical support for the project, contributed to the analysisof the data, interpreted the data, and wrote the first draft of the paper. KScombined the datasets from the original study and PSBC, conductedpreliminary statistical analyses, and contributed to interpretation of the dataand drafts of the manuscript. EH and HB contributed to the design andconception of the study, interpretation of the data, and drafts of themanuscript. All authors read and approved the final manuscript.AcknowledgementsWe acknowledge funding for this study from the University of BritishColumbia Hampton Research Endowment Fund (F08-05671) and for theoriginal cross-sectional study from the British Columbia Medical ServicesFoundation (BCM05-0107). We also acknowledge support from PSBC interms of providing outcome data and the participation of British Columbianpregnant women in the study. The funding bodies did not contribute to thestudy design, the collection, analysis, and interpretation of data, the writingof the manuscript, or the decision to submit the manuscript for publication.Members of the PSBC reviewed the final manuscript for approval as per thecontract for access to the data.Author details1University of British Columbia School of Nursing, T201, 2211 Westbrook Mall,Vancouver, British Columbia, Canada V6T 2B5. 2Research Associate, Divisionof Midwifery, University of British Columbia Department of Family Practice,B. 54, 2194 Health Sciences Mall, Vancouver, British Columbia, Canada V6T 1Z3.3Midwifery Education Program, McMaster University, Hamilton, ON, Canada.Received: 11 July 2011 Accepted: 24 July 2012Published: 3 August 2012References1. Statistics Canada: Birth estimates by Province and Territory. Ottawa, Ontario:Statistics Canada; 2010 [http://www40.statcan.ca/l01/cst01/demo04a-eng.htm].2. 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O’Hana HP, Levy A, Rozen A, Greemberg L, Shapira Y, Sheiner E: The effectof epidural analgesia on labor progress and outcome in nulliparouswomen. J Matern Fetal Neonatal Med 2008, 21:517–521.62. Perkin MR, Bland JM, Peacock JL, Anderson HR: The effect of anxiety anddepression during pregnancy on obstetric complications. Br J ObstetGynaecol 1993, 100:629–634.63. Peterson RA: A meta-analysis of Cronbach’s coefficient alpha. J ConsumerRes 1994, 21:381–391.doi:10.1186/1471-2393-12-78Cite this article as: Hall et al.: A prospective study of effects ofpsychological factors and sleep on obstetric interventions, mode ofbirth, and neonatal outcomes among low-risk British Columbianwomen. BMC Pregnancy and Childbirth 2012 12:78.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitHall et al. BMC Pregnancy and Childbirth 2012, 12:78 Page 10 of 10http://www.biomedcentral.com/1471-2393/12/78


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