The index group consisted of 14 women with severe FOC and who gave birth at a Swedish university hospital. The women communicated their fear at the antenatal healthcare clinic and were referred to an obstetrician at the psychosocial unit of the Department of Obstetrics and Gynaecology. The women were diagnosed with severe FOC according to DSM-IV, i.e., the American Psychiatric Associations diagnostic criteria for severe phobia . They all received the standard counselling based on psycho-education and cognitive behaviour therapy during pregnancy offered to women with FOC. In addition, they were offered continuous support by one of two specially assigned midwives during labour, if they were planned for a vaginal birth. Continuous support was defined as the presence of an experienced midwife with specific training in psychological treatment of women with FOC throughout the labour and birth. The women with FOC met with the selected midwife during the last trimester to establish a trustful relation and to provide the woman with an opportunity to become familiar with the delivery ward. The continuity of care was implemented according to the following protocol:
The woman was invited to the delivery ward for a first meeting with the selected midwife. The partner was also welcomed.
At the first meeting the delivery ward was presented and the delivery rooms were shown. All equipment was explained and tested if this was asked for. In order to meet specific fears or questions and to prepare the woman for events that might occur during the childbirth an external and sometimes a vaginal examination were offered as well as a CTG (cardiotocogram). The examinations and the foetal surveillance were offered in order to expose the women to these routines and thus help the women to get used to exposures that might be fearful to them. Questions were encouraged and the birth process was thoroughly discussed.
A second visit with the selected midwife at the delivery ward was offered if the woman so wished.
The woman was encouraged to contact the midwife by telephone or schedule additional visits to the delivery ward for further support or information if needed.
If a birth plan /contract had not been established together with the obstetrician in routine prenatal care of FOC the midwife and the woman wrote an appropriate document.
Information was given to each woman that the two assigned midwives would do their utmost to attend and assist the woman’s childbirth but that circumstances such as illnesses and other unaccounted situations may occur and in these circumstances a regular midwife would assist the woman according to the birth plan.
Individual support was continuously offered to the two assigned midwives by the obstetrician in charge at the psychosocial unit.
As a reference group, 28 women without FOC according to antenatal care records who gave birth at the same hospital and day as the index women and who received standard labour and birth care were retrospectively chosen.
In order to evaluate the obstetric outcomes, data were extracted from the women’s antenatal and birth records. To explore the woman’s subjective childbirth experience, a structured telephone interview was conducted. After six months, a letter containing information about the telephone interview and emphasizing that participation was voluntary was sent to women both in the index and in the reference group. The interviews were structured and were performed by two medical students in their final year. We chose this approach in order to minimize bias. The students did not have any connection with the treatment of the women and was not involved in implementation of the study. They were specially trained by the psychotherapist in the research team to conduct the interviews. Each woman was interviewed over the telephone. Two women in the index group were excluded, as they did not receive an assigned midwife at the delivery ward due to unknown reasons. One index woman refused to participate in the telephone interview, as she was very unsatisfied with the treatment provided. Two of the women in the control group also declined participation and expressed a negative birth experience as the reason. Finally 11 index women and 26 control women were interviewed. A structured interview guide was developed by the research team and used in the interviews, in order to cover all areas of interest.
The background maternal characteristics derived from the women’s records were maternal age, body mass index (BMI), civil status, occupation, smoking, parity (present pregnancy not included), previous miscarriage, and previous legal abortion.
The obstetric characteristics derived from the delivery records of the present pregnancy were gestational week at childbirth, induction of labour, oxytocin augmentation of labour and Apgar score at 5 min.
The outcome measures of the study were duration of active labour in primiparous and parous women, use of pain relief and frequency of emergency CS and the woman’s subjective experience of the childbirth. Onset of active labour was defined as regular painful uterine contractions, three to four in a 10 min period, and a cervical dilation of three centimetres or more, according to Swedish standard, practiced at all maternity units. The midwife at the delivery ward recorded the time when the regular contractions started. If regular contractions had started at home, the pregnant woman reported the time. Duration of labour was the time between onset of labour and the time of birth. Epidural anaesthesia, paracervical local anaesthesia, nitrous oxide, acupuncture, intravenous morphine were classified as pain relief.
All statistical analyzes were performed using IBM SPSS Version 19 (Armonk, NY, USA). Statistical analyzes included Pearson’s chi-square, Fisher’s exact test and Student’s t-test. Logistic regressions were made with each outcome measure as dependent variable. The answering alternatives of the interview questions were re-categorized into two alternatives when necessary. In all analyzes, a two-sided p-value of ≤ 0.05 was considered significant.
The women gave oral informed consent before participating in the study. The study outline was approved by The Regional Ethical Review Board in Linköping.