INTRODUCTION:

Childbirth is a seminal life event that has always been associated with intense emotions for those engaged directly in it or in a supporting role. Mixed with the joy, excitement and pride of birth, fear has historically cast its shadow on the safety of the mother and the infant¹. Fear is primal. In statistical terms, fear is a continuous variable. It ranges from a commonsense awareness and regard for risks, to life limiting phobias.

Obstetric and psychological researchers have attempted to define, and identify ways to measure and classify fear as it relates to childbirth^2-8 since that early time. Fear of childbirth has been described using terms such as a negative cognitive assessment of the anticipated childbirth feelings of fear and anxiety when facing birth very negative feelings towards birth and the pathological dread and avoidance of childbirth -‘tokophobia’.⁹

Labor is one of the great events in every women’s life, it is an intense process that creates high level of emotional stress and anxiety for a women. During labor the mother needs lots of help for the realization and acceptance of labor as a normal physiological phenomenon. Labor pain is one of the most severe pains which has ever evaluated and its fear is one of the reasons women wouldn’t go for natural delivery and even may complicate the labor process.

Mild fear is considered normal for women during labor and childbirth. But primigravida mother have more fear and this excessive fear increases catecholamine secretion, resulting in more pelvic pain. The stimuli reaching the brain; this in turn magnifies pain perception. As fear heightens, muscle tension increases, the effectiveness of uterine contraction decreases, and discomfort intensifies; thus a cycle of increased fear and anxiety begins. Ultimately this cycle will slow down the progress of labour, anxiety, ambivalence, mood swings, introversion, narrowing of interest, depression, feeling of loneliness and impatience will be experienced during the last week of pregnancy. Fear causes uterine dysfunction and uterine hypoxia which may be the reason for the occurrence of stillbirth.

Fear may be related to herself and her baby, sex of the child, loss of child, fear to have premature child, child with mental retardation or congenital malformation, fear of operation, fear of family’s undesirable attitude of the new environment which may cause for the problem during labor.

Considering different factors which affect experiencing pain, investigator felt a need to assess relationship of FOC with outcome of labor, i.e. if FOC increases does it leads to complicated outcome. As this tool can be very effective and feasible for routine screening of women with FOC which can help to identify the level of FOC in pregnant women and interventions can be suggested to decrease the FOC by educating mothers on labor process, help them cope with the pain, use different techniques to smoothen the labor process etc which in turn will help to have a fruitful outcome and which would be a step contributing in decreasing maternal mortality.

STATEMENT OF THE PROBLEM:

A Descriptive Study To Assess Association Of Fear Of Childbirth (FOC) Among Primigravida Women With Labor Outcome In Selected Municipal Corporation Hospital.

OBJECTIVES OF THE STUDY:

· To assess FOC among Primigravida women.

· To identify labor outcome among Primigravida women assessed for FOC.

· To evaluate association of FOC with outcome of labor among Primigravida women assessed for FOC.

ASSUMPTION:

1 Primigravida women will have fear of childbirth.

2 Fear may affect co operation or ability of women to participate in labor and may affect maternal and fetal outcome.

LIMITATIONS:

· The study is limited to primigravida women in selected municipal corporation hospital.

· The study is limited to 200 sample.

ETHICAL ASPECT:

1. The study proposal was sanctioned by ethical committee.

2. Permission was obtained from the concerned authority of the selected municipal hospital.

3. Informed consent was taken from the participants.

Egeliolu Cetili, Nuray; Denizci Zirek, Zubeyde; Baklan Abal, Fatma (2016), conducted a research on Childbirth and Postpartum Period Fear in Pregnant Women and the Affecting Factors. A descriptive design was used in the study, which was conducted with pregnant women at two obstetric polyclinics of a university hospital in Turkey from January 2014 to July 2014. The population consisted of 143 pregnant women. The data were collected using an individual identification form and the Fear Childbirth and Postpartum Anxiety Scale. The percentage, Kruskall Wallis, Mann-Whitney U and Independent Sample t tests were used to evaluate the differences between the variables. The results of the study reveal that pregnant women are quite fearful of childbirth and the postpartum period. The study concluded that it is necessary to decrease fear of childbirth, because of its negative effects.¹⁰

Faisal, I, et al, (2014), performed. a qualitative study to investigate why primigravidae request caesarean section without any medical indication. Data were gathered through semi-structured interviews, 14 primigravidae who requested caesarean section without any medical indication. reasons for requesting caesarean section were related to fear of childbirth (labour pain, injury to mother or infant), complications after vaginal delivery (vaginal prolapse, urinary incontinence, sexual dysfunction), trust in obstetricians, and lack of trust in maternity ward staff. The main reasons given for requesting caesarean section show that there is urgent need for effective antenatal assessment to enable pregnant women to ask questions and express their concerns. Health care providers should be re-educated about the observance of medical ethics and professional rules in their practices, and change their attitudes and behaviors to vaginal birth. ¹¹

Hall WA, Hauck YL, Carty EM, Hutton EK, Fenwick L, Stoll K. (2009), conducted a cross-sectional descriptive survey to explore women's levels of childbirth fear, sleep deprivation, anxiety, and fatigue and their relationships during the third trimester of pregnancy. Six hundred and fifty nulliparous and multiparous women, 17 to 46 years of age and between 35 and 39 weeks gestation, with uncomplicated pregnancies. Wijma Delivery Expectancy/Experience Questionnaire, were used. In result, Twenty-five percent of women reported high levels of childbirth fear Childbirth fear, fatigue, sleep deprivation, and anxiety were positively correlated. Fewer women attending midwives reported severe fear of childbirth than those attending obstetricians. Women with high childbirth fear were more likely to have more daily stressors, anxiety, and fatigue, as well as less help. Higher levels of anxiety predicted higher levels of childbirth fear among women.¹²

Andersson et al (2004), Investigate the obstetric outcome and health care consumption during pregnancy, delivery, and the early postpartum period in an unselected population-based sample of pregnant women diagnosed with antenatal depressive and/or anxiety disorders, compared with healthy subjects. 1495 sample were taken, to assess demographic characteristics, obstetric outcome, and complications, the medical records of the included women were reviewed. In result significant associations were found between depression and/or anxiety and increased nausea and vomiting, prolonged sick leave during pregnancy and increased number of visits to the obstetrician, specifically, visits related to fear of childbirth and those related to contractions. Planned cesarean delivery and epidural analgesia during labor were also significantly more common in women with antenatal depression and/or anxiety.¹³

RESEARCH METHODOLOGY:

STUDY APPROACH: Quantative

STUDY DESIGN: Non Experimental-Descriptive

SETTING: Selected corporation hospital

POPULATION:

The population of the present study comprises of primigravida women more than 36 weeks.

Target population:

The target population for present study comprises all primigravida more than 36 weeks.

Accessible population:

The accessible population for the present study consists of primigravida pregnant women more than 36 weeks attending antenatal OPD in selected municipal corporation hospital available at the time of study

SAMPLE and SAMPLING TECHNIQUE:

Sample:

In present study, the sample selected were the primigravida women have 36 weeks of gestation.

SAMPLE SIZE- 200

STUDY POPULATION:

Primigravida women attending ANC OPD

SAMPLING TECHNIQUE:

Purposive sampling

INCLUSION CRITERIA:

· Registered Primigravida women more than 36 weeks of gestation

· Primigravida women accessible during the study

· Mothers who can read and write

EXCLUSION CRITERIA:

· Not Willing to Participate

· Primigravida women undergoing Cesarean section.

· Primigravida women with high risk pregnancies.

TOOL PREPARATION:

The standard Wijma delivery expectancy questionnaire was modified by the researcher in context to the fear of childbirth in primigravida women.

a) Extensive review of literature

b) Validation of tool by experts.

DESCRIPTION OF TOOL -

1. Section I: Socio Demographic Profile of mother

2. Section II: Modified Wijma Delivery Expectancy Questionnaire ( version A)

3. Section III: Labor Outcome by observational checklist

1. Delivery details:

· Mode of delivery – Vaginal/Instrumental/Cesarean

· Augmentation of labor

2. Maternal Outcome:

· Mother without Complications

· Mother with Complications (Specify___________)

3. Fetal Outcome:

· Foetal without Complications

· Foetal with Complications (Specify____________)

TECHNIQUE:

The permission was taken from the medical officer of Pune city and consent from the primigravida mother more than 36 weeks. Then the demographic data collected from the primigravida mother more than 36 weeks, then used tool (Modified Wijma Delivery Expectancy Questionnaire) to assess the level of fear and after assessing fear, when mother is in labor i.e from 4cm dilatation the duration will count to know the findings.

Tool was found to be valid and reliable, pilot study was done to find feasibility and problems faced. For final data collection it was planned to select the subjects for study who attended both the antenatal OPD and labor room. To select the sample needed for the study, the investigator approached the proper authorities for obtaining the necessary permission and cooperation. The nature of the study was briefly explained and it was ensured by the investigator that the normal routine of the hospital won’t be disturbed. Demographic data of the primigravida mother more than 36 weeks were collected then by using the modified Wijma delivery expectancy questionnaire assessed the level of fear of childbirth. Data was recorded in the format developed for the purpose.

RESULTS:

Table 1. Demographic Data Of Primigravida Women

Parameters

No of cases

Percentage (n=200)

Age (Yrs)

18 – 20

21 – 23

24 – 26

101

42.5

50.5

Educational status

Secondary

Higher secondary

Graduate

4.5

46.5

Sources of information

Friend

Relative

Newspaper

Internet

200

138

104

100

Type of family

Joint

Nuclear

104

Above table describes compilation of socio demographic characteristics among selected primigravida women.

A) Age –

Majority (50.5%) of primigravida women are seen in age group of 21-23yrs, 42.5% are in age group of 18-20yrs, only 7% are seen in 24-26 yrs.

B) Educational status

Majority (49%) of primigravida women are graduate, 46.5% are higher secondary, only 4.5% are secondary.

C) Sources of information

Majority (100%) of primigravida women were getting information from friends and their relative, 69% are getting information from newspaper ,and 52% are getting information from internet.

D) Type of family –

Majority (104%) of primigravida women belongs to nuclear family and 48% of primigravida women belongs to joint family.

Table 2: Analysis On Fear Of Childbirth (FOC) Among Selected Primigravida Women

Fear of child	No of cases	Percentage
>85 (Present)	152	76
≤ 85 (Absent)	48	24
Total	200	100

Above table describes the analysis on Fear of childbirth (FOC) , majority (76%) primigravida women are having childbirth fear and remaining (24%) of women are not having childbirth fear.

Table 3: a) Analysis on Labor Outcome Among Primigravida Women Assessed For FOC.

Parameters

No of cases

Percentage (n=200)

Duration (Hrs)

Up to 10.15Hrs

>10.15Hrs

164

Mode of delivery

Vaginal

Instrumental

193

96.5

3.5

Augmentation of labor

Oxytocin Drip

cerviprime gel

188

Complicated labour

Prolonged labour

Normal

112

Maternal outcome

Normal

Perineal tear

Instrumental

Post Partum Hemorrhage

169

84.5

5.5

Fetal outcome

Normal

Caput Succedaneum

Low APGAR score

Birth injury

MSL

146

12.5

11.5

The above table describes compilation of labour outcome among selected primigravida women:

A) Duration of labor (hours) - majority (82%) of primigravida women are having labour duration more than 10 hours and 15 min, whereas (18%) primigravida women are having labor duration upto10hrs and 15min.

B) Mode of delivery- majority (96.5%) of primigravida women have delivered vaginally and only 3.5% women had undergone instrumental delivery.

C) Augmentations of labor–majority (94%) of primigravida women are augmented with oxytocin drip, whereas only (6%) of primigravida women are augmented with cerviprime gel.

D) Prolonged labor- majority (56%) of primigravida women have undergone prolonged labor, whereas 44% of primigravida women have undergone normal delivery.

E) Maternal Outcome – majority (84.5%) of women have normal maternal outcome whereas (15.5%) 0f primigravida women delivered with complication, out of which (15.5%) of primigravida women have delivered with perineal tear, (5.5%) of primigravida women have undergone instrumental delivery, 4% of primigravida women have delivered with severe bleeding ie PPH.

F) Fetal outcome -majority of (73%) of fetal outcome is normal, whereas (27%) of fetal outcome is complicated, out of which (12.5%) of fetus have delivered with caput succedaneum, (11.5%) of fetus had low Apgar score after birth and were admitted in NICU, (2%)of fetus have delivered with birth injury, and only 1% of fetus had MSL and were admitted in NICU for observation.

Table 3: b. 1) Association Between Duration Of Delivery And Fear Of Childbirth Among Primigravida Women

Duration (Hrs)	Fear of child		Total
Duration (Hrs)	Present	Absent	Total
Up to 10.15Hrs	0	36	36
>10.15Hrs	152	12	164
Total	152	48	200

Chi-square = 139.02, P<0.0001

In the duration of labor, out of 200, (164) primigravida mother are having labor duration more than 10hrs and 15 min, among which (152) were having FOC and (12) were not having FOC. Remaining 36 primigravida women had labor duration upto 10hrs and 15 min and were not having FOC.

There is significant association found between duration of labor and fear of childbirth (FOC) among primigravida women at (P<0.001).

Table 3: b. 2). Association Between Mode of Delivery and Fear of Childbirth among Primigravida Women

Mode of delivery	Fear of child		Total
Mode of delivery	Present	Absent	Total
Vaginal	145	48	193
Instrumental	7	0	7
Total	152	48	200

Fisher exact test: P = 0.20

In the mode of delivery, out of 200 primigravida mothers (193) delivered vaginally out of which majority of the mothers (145) were having FOC, and (48) were not having FOC. Remaining (7) primigravida mothers delivered with instrumentation who were having FOC.

There is no significant association found between Mode of deliveryand fear of childbirth (FOC) among primigravida women at (P>0.05).

Table 3: b. 3) Association Between Augmentation Of Labour And Fear Of Childbirth Among Primigravida Women

Augmentation of labour	Fear of child		Total
Augmentation of labour	Present	Absent	Total
Oxytocin Drip	142	46	188
cerviprime gel	10	2	12
Total	152	48	200

Fisher exact test: P = 0.73

In the augmentation of labor, out of 200 primigravida women (188) women were augmented by oxytocin drip, out of (142) were having FOC and 46 were not having FOC. Remaining (12) primigravida women were augmented by cerviprime gel, out of (10) were having FOC and (2) were not having FOC.

There is no significant association between augmentation of labor and fear of childbirth as P value is >0.05.

Table 3: b. 4) Association Between Complicated Labour And Fear of Childbirth Among Primigravida Women

Complicated labour	Fear of child		Total
Complicated labour	Present	Absent	Total
Prolonged labour	105	7	112
Normal	47	41	88
Total	152	48	200

Chi-square = 43.97, P<0.0001

In the complicated labor, out of 200 primigravida women (112) women undergone prolonged labor, out of which (105) were having FOC and (7) were not having FOC. Remaining (88) primigravida women undergone normal labor, out of (47) were having FOC and 41 were not having FOC.

There is significant association was found between complicated labor and fear of childbirth (FOC) at P<0.0001

Table 3: b 5) Association Between Maternal Outcome And Fear Of Childbirth Among Primigravida Women

Maternal outcome	Fear of child		Total
Maternal outcome	Present	Absent	Total
Complication	28	3	31
Normal	124	45	169
Total	152	48	200

Chi-square = 4.1259. P<0.05

In the maternal outcome, out of 200 primigravida women (169) are having normal maternal outcome, (124) were having FOC and (45) were not having FOC. Remaining (31) primigravida women are having complicated maternal outcome. Among which 12 were having perineal tear and had FOC, out of which 11 had FOC and 2 were not having FOC, 8 primigravida women had encountered PPH out of which 7 had FOC and 1 was not having FOC.

There is significant association was found between maternal outcome and fear of childbirth (FOC) at P<0.05

Table 3: b. 6) Association Between Fetal Outcome and Fear of Childbirth Among Primigravida Women

Fetal outcome	Fear of child		Total
Fetal outcome	Present	Absent	Total
Complication	50	4	54
Normal	102	44	146
Total	152	48	200

Chi-square = 11.16, P=0.001

In the fetal outcome, out of 200 primigravida women (146) are having normal fetal outcome, of which (102) were having FOC and (44) were not having FOC. Remaining (54) primigravida women are having complicated fetal outcome, 25 fetus had caput out of which 22 primigravida mother with fetus having caput had FOC and 3 primigravida mother with fetus having caput did not had FOC. (23) fetus have low Apgar score out of which 22 primigravida women with fetus having low Apgar score have FOC and 1 primigravida women with fetus having low Apgar score did not had FOC. 4 fetus having birth with mother having FOC. 2 fetus had MSL with mother having FOC.

There is significant association was found between fetal outcome and fear of childbirth (FOC) at P<0.0001. There is significant association was found between maternal outcome and fear of childbirth (FOC) at P<0.05. There is significant association was found between complicated labor and fear of childbirth (FOC) at P<0.0001

CONCLUSION:

Findings of the study suggested that Wijma delivery expectancy questionnaire (version A) screening tool for measuring Fear of childbirth in primigravida women is an easy, cost effective, and patient do not need to undergo any painful procedure cardiovascular risk is an easy, cost effective, and patients do not need to undergo any painful procedure, it may prevent complication while labor process.

IMPLICATIONS OF THE STUDY:

The implication of the study can be discussed in five broad areas namely; clinical nursing practice, nursing education, nursing research and in community setting.

Clinical practice:

Nursing practice includes promotive, preventive and rehabilitative services. Nurses play an important role in rendering supportive and educative care to all primigravida women. This study provided evidence for practicing the effectiveness Modified Wijma delivery expectancy questionnaire –A for primigravida women. Measuring FOC is cost effective for primigravida women and easy for the nurses to apply.

Nursing education:

Nursing education is the means through which nurses are prepared for practice in various setting. The education curriculum must include imparting knowledge as well as emphasize on developing skills which are required to identify and prevent complications. Nursing staff can use the results of the study as an informative illustration. Nursing education should help in inculcating values and sense of responsibility in the all maternity unit/ hospital to use newer and cost effective method to screen the primigravida women with FOC according to the evidence based practice. Birth preparedness sessions has been included in nursing education and this study encourages interdisciplinary researches and evidence based practice. Modified Wijma delivery expectancy questionnaire A, Tool can be included in the curriculum. Students will know the importance of assessing FOC.

Nursing research:

Nursing research is an essential component of today’s nursing education. The research is the only possible method to generate evidence for carrying out nursing care.

It contributes in delivering quality care to our clients. The findings and design of this study can be utilized for conducting further collaborative or interdisciplinary studies.

Community:

Measuring Fear of childbirth is easy, fast and cost effective method with no side effects measuring ABI index is also simple, so it can be monitored safely in the community area. Students as well as nurses will practice assessing FOC of the primigravida mother and accordingly the education can be given for birth preparedness.

RECOMMENDATIONS:

1. A similar study can be done over larger population to generalize the findings.

2. A study can be done to assess the fear of childbirth (Antenatal and postnatal) and practice of nurses about Wijma delivery expectancy questionnaire.

3. Follow-up studies can be done on the same sample to assess association between FOC and Planned cesarean section.

4. A study can be done on effectiveness of birth preparedness classes on maternal and fetal outcome among primigravida women.

5. A Wijma delivery expectancy questionnaire should be implemented in every hospital to assess the FOC of primigravida women to reduce the complication while labor process.

6. In antenatal visit only educate primigravida women about birth preparedness by authority person.

SUMMARY:

This chapter deals with summarization of the research study, bringing forth the major findings of the study, conclusion, nursing implications in nursing practice, education and research as well as the recommendations for further study. In this study, FOC among primigravida is assessed using Wijma delivery expectancy questionnaire by interview method, then observe the labor about maternal and fetal outcome. The study highlights the association of Fear of childbirth among primigravida women with labor outcome.

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Received on 22.02.2018 Modified on 16.04.2018

Int. J. Nur. Edu. and Research. 2018; 6(4):338-344.

DOI: 10.5958/2454-2660.2018.00082.0