Dissatisfaction with the husband support increases childbirth fear among Indonesian primigravida

Abstract

Objective

To investigate the predictors of childbirth fear among Indonesian primigravida.

Method

This cross-sectional study involved 126 third trimester primigravidas in Bekasi city, Indonesia through a cluster sampling. We used the Indonesian version of Marital Adjustment Test (MAT), Perceived Stress Scale (PSS), Pregnancy-Related Anxiety Questionnaire (PRAQ-R2), and Wijma Delivery Experience/Expectancy Questionnaire (WDEQ-A).

Results

Severe childbirth fear was reported by 45.2% women. The women's satisfaction of the husband support (OR 11.96, 95% CI 4.3–33.1) and anxiety (OR 3.37, 95% CI 1.4–7.9) were found as the predictors of childbirth fear. However, knowledge regarding childbirth and stress were identified as two factors significantly related to childbirth fear (p < .005).

Conclusion

The lower satisfaction of the husband support increased the probability of childbirth fear. It is recommended for health care providers to facilitate husbands throughout antenatal care to support his wife in preventing childbirth fear.

Introduction

Mental health problems become a global issue experienced by almost every world population. As many as 15% of pregnant women suffer from it in the prenatal and postnatal period. Maternal mental health problems, especially childbirth fear encountered in pregnancy can continue until just before delivery.^1,2 If it is not treated, childbirth fear may have a long-term impact on maternal health. Mothers may experience an increase in blood pressure, prolonged labor, increased labor by cesarean section, posttraumatic stress disorder (PTSD), postpartum depression, and negative childbirth experience that may reoccur in their future childbirth.^3–5

Childbirth fear is one of the maternal mental health problems that are common among pregnant women in the world. Childbirth fear is a negative thought and feeling regarding childbirth. Childbirth fear occurs in 20–25% of pregnant women in Europe with various levels ranging from mild to severe.⁶ The previous studies showed a high variation of childbirth fear in Europe, Australia, and Asia, which are 11%, 4.8%, and 10.6%, respectively.^7–9 In India, it was found that 17.7% of pregnant women suffered from childbirth fear.¹⁰ Unlike other countries, in Indonesia, specific data regarding childbirth fear are not found, but a report mentions that 55% of pregnant women were in anxiety.¹¹

Some factors may affect childbirth fear.¹ The previous studies in Europe, Australia, and Asia reported that there were three significant factors associated with childbirth fear (p < 0.001) including maternal age, knowledge about the delivery process, and psychological factors.^6,8,9 Primigravida (a woman who is having the first pregnancy) in Europe has a higher level of childbirth fear compared to multigravida (a woman who is pregnant for at least a second time).⁶ Also, primigravida has multiple sources of fear, the most typical one is the fear of labor pain.¹² Husband support was shown to be able to decrease the childbirth fear.¹³

Supportive care during pregnancy and childbirth have become part of the worldwide health services.¹⁴ Although the maternal mortality rate (MMR) in Indonesia is still high, the government program should not just take necessary measures to prevent obstetric complications¹⁵ but also address the psychological problems. Detecting childbirth fear especially for the first time pregnancy allows the health care providers to determine the appropriate intervention so that the fear does not continue until labor. As mentioned previously, in Indonesia there is no data available specifically on childbirth fear. However, a prior study in Indonesia found that most husbands (97%) provided adequate support during pregnancy.¹³ This fact opens the possibility for other factors that influence childbirth fear in Indonesia. In this study, we aimed to investigate the predictors of childbirth fear among Indonesian primigravida.

Method

This study was a cross-sectional study conducted in four Community Health Centers in Bekasi city, West Java, Indonesia for a month. The sample was primigravida in the third trimester with at least high school/equivalent education. We excluded the pregnant women if they had the Edinburgh Postpartum Depression Scale (EPDS) scores more than 12. A total of 126 participants were selected through a cluster sampling. The primary sample unit (PSU) was Kota Bekasi, the secondary sample units (SSU) were four Community Health Centers in Kota Bekasi which were selected randomly, and the tertiary sample unit (TSU) was the third trimester primigravida. This study was approved by the Ethics Committee of Faculty of Nursing, Universitas Indonesia.

Maternal age was answered through a categorical question, while knowledge about childbirth was examined through 22 items of knowledge about childbirth questionnaire. Satisfaction on support from husband was obtained through 15-item Marital Adjustment Test (MAT) and the stress was assessed by using 10-item Perceived Stress Scale (PSS). Furthermore, 10 Pregnancy Related Anxiety Questionnaire Revised-2 (PRAQ-R2) items were used to measure childbirth-related anxiety, and 33 items of the Wijma Delivery Expectancy/Experience Questionnaire Version A (WDEQ-A) statement for childbirth fear. Of all these instruments, only WDEQ-A and PRAQ-R2 were translated into Indonesian language. Then the reliability and validity tests were carried out on both tools at a Community Health Center in Bantar Gebang, Bekasi. The results were r alpha = 0.94 for WDEQ-A and 0.80 for PRAQ-R2.

Results

Most primigravidas had a low risk age, had good knowledge about childbirth, were satisfied with support from their husband, had severe stress and yet low anxiety level. As for the level of childbirth fear, more primigravida in this study experienced mild childbirth fear (Table 1).

Table 1.

Maternal age, knowledge about childbirth, psychological factor and childbirth fear in primigravida.

	N	Percentage (%)
Maternal age
High risk	11	8.7
Low risk	115	91.3
Knowledge about childbirth
Less	27	21.4
Good	99	78.6
Satisfaction with support from husband
Satisfied	87	69
Dissatisfied	39	31
Stress
Mild	47	37.3
Severe	79	62.7
Anxiety related childbirth
Low	69	54.8
High	57	45.2
Childbirth fear
Mild	69	54.8
Severe	57	45.2

Variables that showed a relationship with childbirth fear included knowledge about childbirth, satisfaction with support from husband, stress, and anxiety (p < 0.05), whereas maternal age, is not related to childbirth fear (p > 0.05) (Table 2).

Table 2.

Factors related to childbirth fear in primigravida.

	Childbirth fear				OR
	Mild		Severe
	N	%	N	%
Age
High risk	3	27.3	8	72.7	0.28
Low risk	66	57.4	49	42.6
Knowladge about childbirth
Less	8	29.6	19	70.4	0.26^*
Good	61	61.6	38	38.4
Satisfaction with support from husband
Dissatisfied	6	15.4	33	86.4	10.7^*
Satisfied	63	72.4	24	27.6
Stress
Severe	36	45.6	43	54.4	0.35^*
Mild	38	70.2	14	29.8
Anxiety related childbirth
High	20	35.1	37	64.9	3.13^*
Low	49	71	20	29

*

p value <0.05, 95% CI.

The result (Table 2) showed that out of 87 primigravida who were satisfied of support from husband, there were 63 (72.4%) primigravida experiencing mild childbirth fear. On the other hands, out of 39 primigravida who were dissatisfied with support from husband, there were 33 (86.4%) primigravida reporting severe childbirth fear. The dissatisfaction with husband support may therefore be associated with increased childbirth fear in primigravida.

The results of the multivariate analysis are presented in Table 3. The results showed that the variables which predicted the childbirth fear in primigravida were satisfaction with support from their husband and anxiety. The order of the variables that have the most influence was satisfaction with support from husband (OR = 11.96, 95% CI 4.3–33.1) and anxiety (OR = 3.37, 95% CI 1.4–7.9).

Table 3.

Logistic regression analysis.

Variable	Sig	Exp (B)	95% CI
			Lower	Upper
Satisfaction on support from husband	0.001	11.96	4.3	33.1
Anxiety related childbirth	0.005	3.37	1.4	7.9

Discussion

The level of mild childbirth fear in this study is in line with the previous study results by Toohil et al.⁸ and Molgora et al.⁷ which showed that only about a quarter of primigravida had to experience childbirth fear. However, the prevalence of severe childbirth fear in this study is different from previous studies which found no more than 25% having severe level of childbirth fear.^10,16 These varied results might be caused by the use of different instruments in each study. This finding also cannot explain the theory of Childbirth without Fear which posits that childbirth should be without fear.¹⁷ None of the primigravida in this study had a childbirth fear score of 0. It indicated that all primigravida had some degree of fear of delivery. The source of fear that might occur is the fear of labor pain (12).

The childbirth fear which tended to be of good value in this study might also be caused by the socioeconomic factors. Most primigravida who go to primary care have a socioeconomic level that tends to be homogeneous, which is in the lower-middle level. In the values and cultures of the Indonesian people, primigravida commonly considers labor pain not as scary thing so that they can undergo it without concern. In the developed countries, the rate of cesarean section increases,¹⁸ while Indonesia is also witnessing the increasing trend of cesarean section. The choice of cesarean section delivery method for the women of middle to upper economic level mostly come from the request from the primigravida themselves due to the perceived fear and anxiety with regards to childbirth.¹⁹

The socio-cultural view of the Indonesian people plays a role in the delivery process.²⁰ Indonesian people consider that pregnancy is a gift that must be lived and thanked so that childbirth is not burdensome and not so frightening. The analysis is in line with the study findings in countries with strong socio-cultural aspects such as Iran and Nepal, in which their social and cultural values hold a central role in decision making related to childbirth.^21,22

Mild childbirth fear found in this study might be related to the knowledge about childbirth which was also good. This could be pertinent to the fact that all primigravida in our study had a relatively high educational background. Therefore, they could find the information and learn about the delivery process more easily. Previous studies also suggested that the pregnant women with a higher level of education showed good knowledge about the delivery process and tended to feel a lesser childbirth fear.^23,24 These findings are supported by a former study on third trimester pregnant women in Indonesia which indicated that most women had good knowledge.²⁵ However, it must be ensured that the source of information obtained was correct.

The significant relationship between stress and childbirth fear was also identified by previous studies.⁶ The majority of primigravida in this study experienced severe stress while our instruments only measured stress in general. The stress might occur due to a stressor other than pregnancy, such as a history of abortion²⁶ and bad experiences in life.⁶ The conditions outside of pregnancy can also be a stressor that triggers childbirth fear.

Socio-economic conditions that were not examined in this study might also influence the way participants filled out their answers. Financial conditions, e.g. related to work and family income, may cause more stress compared to the stress of facing labor itself. A research related to economic status showed a significant relationship with the incidence of childbirth fear.^8,27

Satisfaction with support from the husband was found to have the most predictive influence on childbirth fear. This result is consistent with research findings of Molgora et al.⁷ and Gao et al.²⁶ that the more dissatisfied the women, the more severe their childbirth fear. The kind of support needed by primigravida is supportive support such as antenatal involvement until childbirth and doing activities together.²⁸

According to the socio-cultural values of the Indonesian people, the first child is highly anticipated and considered as a gift so that the whole family, especially the husband, is very enthusiastic and happy to welcome the first child. Therefore, the husband gives more attention to his wife and is even willing to do anything to make her happy. With such an extraordinary support, the primigravida women felt satisfied with the husband's support and ready to undergo the childbirth.

Moreover, the involvement and support of the husband can increase the wife's satisfaction. Primigravida who are satisfied with the husband support will be better prepared to face their childbirth and feel accompanied. The husband support can also help them manage their anxiety related to childbirth process, hence minimizing the childbirth fear.^6,13 In addition to the support given by the husband, primigravida in Indonesia also received support from their parents or in-laws. Therefore, they could have more sources of attention and assistance. The women became happier and convinced that they have abundant support. On the other hand, the primigravida who had been disturbed with their feelings and thoughts might develop anxiety and childbirth fear.^7,29 Severe stress experienced by the primigravida might also trigger anxiety and fear related to childbirth. Severe childbirth fear is bad for women. Prolonged labor duration, increased blood pressure, and changes in maternal adaptation during labor can harm both the mother and the fetus.³⁰

Apart from what we have pointed out above, we also identified some limitations in this study. This study is only limited to primary health care so that it cannot be generalized to the various socio-economic conditions of Indonesian people. The beliefs and socio-cultural values of the Indonesian people have also not been discussed.

The lower satisfaction with support from husband increased the probability of childbirth fear. Satisfaction with the support from husband and anxiety were the important predictors of childbirth fear. Mothers who are dissatisfied with support from their husband are at risk of experiencing severe childbirth fear as well as mothers who experience severe anxiety. Nurses and other health care provider have an essential role to facilitate the husband to take part during antenatal care so that the husband can be involved during the childbirth process.

The future research conducted in the broader scope is highly recommended. A qualitative approach is also needed to explore deeply the forms of support needed by pregnant women. The appropriate interventions should be developed to manage childbirth fear including how to improve the husband's role during childbirth, from prenatal to postnatal period.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgements

This study is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1845/UN2.R3.1/HKP.05.00/2018.