Is fear of childbirth related to the woman's preferred location for giving birth? A Dutch low-risk cohort study.

BACKGROUND: In The Netherlands, women with low-risk pregnancy are routinely given the option of home birth, providing a unique opportunity to study the relationship between fear of childbirth (FOC) and preference for childbirth location, and whether women experience higher FOC when the actual location differs from their preference. METHODS: In this prospective cohort study, 331 nulliparous and parous women completed a questionnaire at gestational week 30 (T1) and two months postpartum (T2). FOC was assessed using versions A (T1) and B (T2) of the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ). RESULTS: At T1, women who preferred home birth had significantly lower FOC compared with women who preferred a hospital birth (mean ± SD W-DEQ scores: 55 ± 19.8 and 64 ± 18.3, respectively, P < .01). About 28% of women who responded at T2 gave birth at home. Congruence between the preferred and actual childbirth location was not predictive of FOC assessed at T2 when adjusted for obstetric and psychological variables. In an extended analysis, we found that except for prepartum FOC, the following variables also correlated with postpartum FOC: being referred because of complications and poor neonatal condition. CONCLUSIONS: Compared to women who prefer hospital birth, women who prefer home birth have lower prepartum and postpartum FOC. Giving birth at a location other than the preferred location does not appear to affect postpartum FOC. Whether giving birth at home or in the hospital, caregivers should pay extra attention to women with high FOC because they are vulnerable to postpartum FOC, especially after a complicated birth and referral.

Severe fear of childbirth indicates high perinatal costs for Swedish women giving birth to their first child.

INTRODUCTION: The objective of this study was to calculate costs associated with severe fear of childbirth (FOC) during pregnancy and peripartum by comparing two groups of women expecting their first child and attending an ordinary antenatal program; one with low FOC and one with severe FOC. MATERIAL AND METHODS: In a prospective case-control cohort study one group with low FOC [Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) sum score ≤60, n = 107] and one with severe FOC (W-DEQ ≥85, n = 43) were followed up till 3 months postpartum and included in the analysis. Medical records were assessed and medical parameters were mapped. Mean costs for healthcare consumption and sick leave during pregnancy were calculated and compared. RESULTS: When means were compared between the groups, the group with severe FOC had more visits for psychosocial reasons (p = 0.001) and more hours on sick leave (p = 0.03) during pregnancy, and stayed longer at the maternity ward (p = 0.04). They also more seldom had normal spontaneous deliveries (p = 0.03), and more often had an elective cesarean section on maternal request (p = 0.02). Postpartum, they more often than the group with low FOC paid visits to the maternity clinic because of complications (p = 0.001) and to the antenatal unit because of adverse childbirth experiences (p = 0.001). The costs for handling women with severe FOC was 38% higher than those for women with low FOC. CONCLUSION: Women with severe FOC generate considerably higher perinatal costs than women with low FOC when handled in care as usual.

Internet-provided cognitive behaviour therapy of posttraumatic stress symptoms following childbirth-a randomized controlled trial.

The aim of this study was to analyse the effects of trauma-focused guided Internet-based cognitive behaviour therapy for relieving posttraumatic stress disorder (PTSD) symptoms following childbirth, a problem that about 3% women encounter postpartum. Following inclusion, 56 traumatized women were randomized to either treatment or to a waiting list control group. Primary outcome measures were the Traumatic Event Scale (TES) and Impact of Event Scale-Reversed (IES-R). Secondary measures were Beck depression inventory II, Patient Health Questionnaire (PHQ-9), Beck Anxiety Inventory, Quality Of Life Inventory and the EuroQol 5 Dimensions. The treatment was guided by a clinician and lasted eight weeks and comprised eight modules of written text. The between-group effect size (ES) was d = .82 (p < .0001) for the IES-R. The ES for the TES was small (d = .36) and not statistically significant (p = .09). A small between-group ES (d = .20; p = .02) was found for the PHQ-9. The results from pre- to post-treatment showed large within-group ESs for PTSD symptoms in the treatment group both on the TES (d = 1.42) and the IES-R (d = 1.30), but smaller ESs in the control group from inclusion to after deferred treatment (TES, d = .80; IES-R d = .45). In both groups, the treatment had positive effects on comorbid depression and anxiety, and in the treatment group also on quality of life. The results need to be verified in larger trials. Further studies are also needed to examine long-term effects.

'I will be at death's door and realize that I've wasted maybe half of my life on one body part': the experience of living with body dysmorphic disorder.

OBJECTIVES: The purpose of this study was to explore the experiences of patients living with body dysmorphic disorder (BDD), including their experiences with the health care system. METHODS: Fifteen individuals with BDD were interviewed, and interpretive description was used to analyse the interviews. RESULTS: The following six themes were identified: being absorbed in time-consuming procedures, facing tension between one's own ideal and the perceived reality, becoming the disorder, being restricted in life, attempting to reduce one's problems and striving to receive care. The overarching concept derived from the themes was feeling imprisoned - struggling to become free and to no longer feel abnormal. CONCLUSIONS: Ideas of imprisonment and abnormality compose the entire experience of living with this disorder. Although the participants suffered greatly from their BDD, these patients encountered difficulties in accessing health care and had disappointing experiences during their encounters with the health care system. Therefore, it is important to increase awareness and knowledge of BDD among health care professionals to ensure that patients with BDD receive the appropriate care.

Prevalence of body dysmorphic disorder among Swedish women: a population-based study.

BACKGROUND: Body dysmorphic disorder (BDD) is characterized by a highly distressing and impairing preoccupation with nonexistent or slight defects in appearance. Patients with BDD present to both psychiatric and non-psychiatric physicians. A few studies have assessed BDD prevalence in representative samples of the general population and have demonstrated that this disorder is relatively common. Our primary objective was to assess the prevalence of BDD in the Swedish population because no data are currently available. METHODS: In the current cross-sectional study, 2891 randomly selected Swedish women aged 18-60 years participated. The occurrence of BDD was assessed using the Body Dysmorphic Disorder Questionnaire (BDDQ), which is a validated self-report measure derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria for BDD. In addition, symptoms of depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS). RESULTS: The prevalence of BDD among Swedish women was 2.1%. The women with BDD had significantly more symptoms of depression and anxiety than the women without BDD. Depression (HADS depression score ≥ 8) and anxiety (HADS anxiety score ≥ 8) were reported by 42% and 72% of the women with BDD, respectively. CONCLUSIONS: The results of the present study indicate that BDD is relatively common among Swedish women (2.1%) and that it is associated with significant morbidity.

Treatment of severe fear of childbirth with haptotherapy: design of a multicenter randomized controlled trial.

BACKGROUND: About six percent of pregnant women suffer from severe fear of childbirth. These women are at increased risk of obstetric labour and delivery interventions and pre- and postpartum complications, e.g., preterm delivery, emergency caesarean section, caesarean section at maternal request, severe postpartum fear of childbirth and trauma anxiety. During the last decade, there is increasing clinical evidence suggesting that haptotherapy might be an effective intervention to reduce fear of childbirth in pregnant women. The present study has been designed to evaluate the effects of such intervention. METHODS/DESIGN: Included are singleton pregnant women with severe fear of childbirth, age ≥ 18 year, randomised into three arms: (1) treatment with haptotherapy, (2) internet psycho-education or (3) care as usual. The main study outcome is fear of childbirth. Measurements are taken at baseline in gestation week 20-24, directly after the intervention is completed in gestation week 36, six weeks postpartum and six months postpartum. Secondary study outcomes are distress, general anxiety, depression, somatization, social support, mother-child bonding, pregnancy and delivery complications, traumatic anxiety symptoms, duration of delivery, birth weight, and care satisfaction. DISCUSSION: The treatment, a standard haptotherapeutical treatment for pregnant women with severe fear of childbirth, implies teaching a combination of skills in eight one hour sessions. The internet group follows an eight-week internet course containing information about pregnancy and childbirth comparable to childbirth classes. The control group has care as usual according to the standards of the Royal Dutch Organisation of Midwives and the Dutch Organization of Obstetrics and Gynaecology. TRIAL REGISTRATION: This trial was entered in the Dutch Trial Register and registered under number NTR3339 on March 4th, 2012.

A randomized controlled trial of guided Internet-delivered cognitive behavioral therapy for erectile dysfunction.

INTRODUCTION: Men with erectile dysfunction are often worried about their condition, have interpersonal difficulties, and have a reduced quality of life. Internet-delivered cognitive behavior therapy (ICBT) has been shown effective for a number of health problems but evidence is limited concerning the treatment of erectile dysfunction. AIM: The study investigated the effects of ICBT for erectile dysfunction. METHODS: Seventy-eight men were included in the study and randomized to either ICBT or to a control group, which was an online discussion group. Treatment consisted of a 7-week Web-based program with e-mail-based therapist support. Each therapist spent an average of 55 minutes per participant. MAIN OUTCOME MEASURE: The International Index of Erectile Functioning five-item version was administered via the telephone at pretreatment, post-treatment, and 6 months after receiving ICBT. RESULTS: At post-treatment, the treatment group had significantly greater improvements with regard to erectile performance compared with the control group. Between-group differences at post-treatment were small (d = 0.1), but increased at the 6-month follow-up (d = 0.88). CONCLUSIONS: This study provides support for the use of ICBT as a possible treatment format for erectile dysfunction.

Long-term coital behaviour in women treated with cognitive behaviour therapy for superficial coital pain and vaginismus.

The purpose of the present study was to investigate long-term coital behaviour in women treated with cognitive behaviour therapy (CBT) for superficial coital pain and vaginismus. Data were taken from a questionnaire concerning long-term coital behaviour sent to 59 women who presented to Linköping University Hospital because of superficial coital pain, had been diagnosed with vaginismus, and had been treated with CBT. Data were also traced from therapy records: mean follow-up time was 39 months, the women had suffered for an average of almost 4 years, and required a mean of 14 treatment sessions. Forty-four of the 59 women returned the questionnaire, for a response rate of 74.6%. At follow-up, 81% of the treated women had had intercourse. A majority (61%) rated their ability to have intercourse without pain as 6 or higher (on a scale from 0-10), and 61% rated their ability to enjoy intercourse as 6 or higher (on a scale from 0-10). The proportion of women with positive treatment outcome at follow-up ranged from 81% (able to have intercourse) to 6% (able to have pain-free intercourse). An ability to have intercourse at end of therapy was maintained at follow-up. Two-thirds of the women reported high fulfillment of individual treatment goals. At follow-up, the women estimated a significantly higher self-worth as sex partners, and as women and human beings, than before treatment. Twelve per cent of the original sample had healed after a few assessment sessions and without treatment.

Lifetime history of abuse, suffering and psychological health.

BACKGROUND: In a representative Swedish sample, we investigated lifetime prevalence of physical, sexual and psychological abuse of women and their current suffering. The relationship between current suffering from abuse and psychological health problems was also studied. METHOD: The study was cross-sectional and population-based. The Abuse Screening Inventory (ASI), measuring experiences of physical, sexual and psychological abuse and including questions on health and social situation, was sent by mail to 6000 women, randomly selected from the population register. The questionnaire was completed and returned by 4150 (70%) of 5896 eligible women. RESULTS: 27.5% of the women reported abuse of any kind. Of those, 69.5% reported current suffering from abuse. Abused suffering women reported more anxiety, depression and sleep disturbances, and a less advantageous social situation than both non-abused and abused non-suffering women. Also, abused non-suffering women reported more depression than non-abused women. Somatization was reported more often by both abused suffering and non-suffering women than by non-abused women, with no difference between suffering and non-suffering women when adjusted for possible confounders. CONCLUSION: A majority of abused women, when investigating lifetime history of abuse, report current suffering thereof, which warrants considering abuse an important societal problem. Suffering could be a valuable construct, possibly useful to assess psychological health problems normally not captured by existing diagnostic instruments, although further investigations of the concept are needed.

Preferred and actual mode of delivery in relation to fear of childbirth.

PURPOSE: This prospective cohort study aimed to investigate the interrelation between preferred/actual mode of delivery and pre- and postpartum fear of childbirth (FOC). MATERIAL AND METHODS: Participants from 13 midwifery practices and four hospitals in Southwest Netherlands filled out questionnaires at 30 weeks' gestation (n = 561) and two months postpartum (n = 463), including questions on preferred mode of delivery, the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) and Hospital Anxiety Depression Scale (HADS). Results were related to obstetric data. RESULTS: Both severe FOC (OR 7.0, p < .001) and previous Cesarean section (CS) (OR 16.6, p < .001) predicted preference for CS. Severe prepartum FOC also predicted actual CS. Preferring a vaginal delivery (VD) and actually having a CS predicted higher postpartum W-DEQ scores (partial r = 0.107, p < .05). Other significant predictors for high postpartum W-DEQ scores were high prepartum W-DEQ (partial r = 0.357) and HADS anxiety scores (partial r = 0.143) and the newborn in need of medical assistance (partial r = -0.169). CONCLUSIONS: Women preferring a VD but ending up with a CS are at risk for severe FOC postpartum, while the same risk was not demonstrated for women who preferred a CS but had a VD. Prepartum FOC is strongly associated with postpartum FOC, regardless of congruence between preferred and actual mode of delivery.

"It is always on my mind": women's experiences of their bodies when living with hirsutism.

Many women suffer from excessive hair growth, often in combination with polycystic ovarian syndrome (PCOS). It is unclear how hirsutism influences such women's experiences of their bodies. Our aim is to describe and interpret women's experiences of their bodies when living with hirsutism. Interviews were conducted with 10 women with hirsutism. We used a qualitative latent content analysis. Four closely intertwined themes were disclosed: the body was experienced as a yoke, a freak, a disgrace, and as a prison. Hirsutism deeply affects women's experiences of their bodies in a negative way.

Haptotherapy as a new intervention for treating fear of childbirth: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of haptotherapy on severe fear of childbirth in pregnant women. DESIGN: Randomized controlled trial. SETTING: Community midwifery practices and a teaching hospital in the Netherlands. POPULATION OR SAMPLE: Primi- and multigravida, suffering from severe fear of childbirth (N = 134). METHODS: Haptotherapy, psycho-education via Internet and care as usual were randomly assigned at 20-24 weeks of gestation and the effects were compared at 36 weeks of gestation and 6 weeks and 6 months postpartum. Repeated measurements ANOVA were carried out on the basis of intention to treat. Since there were crossovers from psycho-education via Internet and care as usual to haptotherapy, the analysis was repeated according to the as treated principle. MAIN OUTCOME MEASURES: Fear of childbirth score at the Wijma Delivery Expectancy/Experience Questionnaire. RESULTS: In the intention to treat analysis, only the haptotherapy group showed a significant decrease of fear of childbirth, F(2,99) = 3.321, p = .040. In the as treated analysis, the haptotherapy group showed a greater reduction in fear of childbirth than the other two groups, F(3,83) = 6.717, p < .001. CONCLUSION: Haptotherapy appears to be more effective in reducing fear of childbirth than psycho-education via Internet and care as usual.

Post-coital burning pain and pain at micturition: early symptoms of partial vaginismus with or without vulvar vestibulitis?

Twenty-four women with partial vaginismus with or without vulvar vestibulitis participated in a semi-structured telephone interview concerning early signs and development of their pain symptoms during/after intercourse. At the onset of the problem, pain after intercourse was more common than pain during penetration. Pain intensity during penetration increased from the onset of the problem to when the women ceased having intercourse. Pain during penetration lasted for 1 minute, and was most often described as sharp/incisive/bursting, while pain after intercourse had a duration of 2 hours and was described as burning and/or smarting. Post-coital pain during micturition was described by 70% of the women.

Post-traumatic stress disorder following childbirth: current issues and recommendations for future research.

BACKGROUND: An increasing body of research shows that a proportion of women experience significant symptoms of Post-Traumatic Stress Disorder (PTSD) following childbirth. AIMS AND METHOD: An international group of researchers, clinicians, and user-group representatives met in 2006 to discuss the research to date into PTSD following childbirth, issues and debates within the field, and recommendations for future research. This paper reports the content of four discussions on (1) prevalence and comorbidity, (2) screening and treatment, (3) diagnostic and conceptual issues, and (4) theoretical issues. CONCLUSIONS: Current knowledge from the perspectives of the researchers is summarized, dilemmas are articulated and recommendations for future research into PTSD following childbirth are made. In addition, methodological and conceptual issues are considered.

Somatization in abused women.

BACKGROUND: The association between abuse and somatization has been less systematically investigated than other abuse-related outcomes. Moreover, such studies have given inconsistent results. Therefore, the aim of the present study was to investigate the relation between somatization and lifetime exposure to physical, sexual, and psychological abuse. METHODS: A total of 800 women, 400 reporting abuse and 400 reporting no abuse in a previous randomized, population-based study, were sent two questionnaires: SOMAT, a questionnaire on somatization, and the Abuse Inventory (AI). Of 781 eligible women, 547 participated (70% response rate). RESULTS: Psychological abuse of both limited (6 months-2 years) and prolonged duration (>2 years) was associated with somatization (OR = 2.45, 95% CI 1.37-4.40 and OR = 3.09, 95% CI 1.52-6.30, respectively). Sexual abuse without penetration was associated with somatization (OR = 2.47, 95% CI 1.17-5.20), but sexual abuse with penetration was not. Physical abuse was not associated with somatization when adjustments for other kinds of abuse were made. Being abused in adulthood and in both adulthood and childhood was associated with somatization (OR = 4.20, 95% CI 2.45-7.20 and OR = 2.90, 95% CI 1.69-4.90, respectively), whereas being abused in childhood only was not. CONCLUSIONS: Abuse of women is associated with somatization. Other factors than severity of abuse, such as whether the abused woman herself perceives her experience as abuse, seem to be more decisive for developing somatization in abused women. Abuse should be taken into account when meeting women with somatization symptoms as patients.

Medical students learning the pelvic examination: comparison of outcome in terms of skills between a professional patient and a clinical patient model.

OBJECTIVE: To compare two models of learning the pelvic examination (PE) for medical students, with professional patients (PP) or with clinical patients (CP), by measuring perceived distress and learning outcome in terms of skills. METHODS: Prospective longitudinal study. Assessments of self-perceived distress on four occasions at the prospect of performing a PE. Evaluation of the learning session (LS) and clinical clerkship concerning outcome of palpation skills. RESULTS: During the LS, students in the PP model (PP students) received enough guidance from their coaches, were certain they had palpated the uterus and at least one ovary, and were less distressed afterwards compared with students who were instructed using the CP model (CP students). During the clinical clerkship, the PP students performed twice as many PEs as CP students did and had more often confirmed palpating the uterus and an ovary. CONCLUSION: PP students were more skilful in palpating the uterus and ovaries and performed more PEs during the clinical clerkship than did CP students. PRACTICE IMPLICATIONS: Engaging healthy and voluntary women as PPs takes time and effort. It is, however, worthwhile as it increases the confidence of students who perform PEs, makes them more competent, and ultimately improves their skills in performing the examination during their clinical clerkship.

A model for critical review of literature - with vaginismus as an example.

In this article we present a behavioral model for the critical review of the literature within a certain research field, using vaginismus as an example. We searched the literature for the title word "vaginismus" and analyzed to what extent the articles dealt with the following seven categories: prevention, etiology, maintaining factors, consequences, object of intervention, method of intervention, and method of evaluation. In each category we scrutinized the content of the articles for biological, psychological, social, relational, and gender aspects. Quality requirements of etiological and treatment studies were then added and the results presented in a "quality-adjusted" model. There were 102 articles during 1985-2001, of which 22 were included in the review. Most of the articles deal with supposed predisposing factors of etiology and different aspects of intervention. Only a few articles discuss precipitating factors, maintaining factors, or consequences of the problem. No article had a gender analysis. Only 11 of the articles fulfilled some of the proposed quality criteria. We found the behavioral model with quality requirements useful for classifying and evaluating the literature of vaginismus. The model may also be used as a guide to design methodologically good studies.

Body dysmorphic disorder in female Swedish dermatology patients.

BACKGROUND: Individuals with body dysmorphic disorder (BDD) are highly distressed and impaired owing to perceived defects in their physical appearance that are not noticeable to others. They are frequently concerned about their skin and often present to dermatologists rather than psychiatrists. However, BDD patients attending dermatology clinics may be at risk of not receiving an appropriate assessment and beneficial treatment. The aims of this study were to estimate the BDD prevalence rate among Swedish female dermatology patients and to assess the psychological condition of BDD patients compared to that of other dermatology patients. METHODS: The occurrence of BDD was estimated using the Body Dysmorphic Disorder Questionnaire (BDDQ), a validated self-report measure for BDD. Symptoms of depression and anxiety were measured by the Hospital Anxiety and Depression Scale (HADS), and quality of life was assessed using the Dermatology Life Quality Index (DLQI). RESULTS: The prevalence rate of BDD among female Swedish dermatology patients was 4.9% (95% CI 3.2-7.4). Anxiety (HADS A ≥ 11) was 4-fold more commonly reported by patients with positive BDD screening (48% vs. 11%), and depression (HADS D ≥ 11) was over 10-fold more common in patients with positive BDD screening (19% vs. 1.8%) (P < 0.001). The median DLQI score was 18 in the BDD group, compared to a score of 4 in the non-BDD group (P < 0.001). CONCLUSIONS: Our results indicate that BDD is fairly common among female Swedish dermatology patients (4.9%) and that BDD patients have high levels of depression and anxiety and severely impaired quality of life.

The longitudinal course of post-traumatic stress after childbirth.

Post-traumatic stress was assessed in early and late pregnancy, and 1, 4, 7, and 11 months postpartum by means of questionnaires among 1224 women. Thirty-seven women (3%) had post-traumatic stress (meeting criteria B, C, and D for PTSD) at least once within 1-11 months postpartum. In pregnancy, depression, severe fear of childbirth, 'pre'-traumatic stress, previous counseling related to pregnancy/childbirth, and self-reported previous psychological problems were associated with an increased risk of having post-traumatic stress within 1-11 months postpartum. Sum-scores of post-traumatic stress did not decrease over time among women who at least once had post-traumatic stress (criteria B, C, and D) within 1-11 months postpartum. Women with post-traumatic stress also showed a decrease in perceived social support over time postpartum.

Psychological well-being improves in women with breast cancer after treatment with applied relaxation or electro-acupuncture for vasomotor symptom.

The aim of this study was to evaluate the effect of applied relaxation and electro-acupuncture (EA) on psychological well-being in breast cancer-treated women with vasomotor symptoms. Thirty-eight breast cancer-treated postmenopausal women with vasomotor symptoms were included in the study. They were randomized to either treatment with electro-acupuncture (EA) (n = 19, three of them with tamoxifen) or applied relaxation (AR) (n = 19, five of them with tamoxifen) over a 12-week study period with six months follow-up. Vasomotor symptoms were registered daily. A visual analog scale was used to assess climacteric symptom, estimation of general well-being was made using the Symptom Checklist, and mood using the Mood Scale. These were applied during treatment and at follow-up. In total 31 women completed 12 weeks of treatment and six months of follow-up. Hot flushes were reduced by more than 50%. Climacteric symptoms significantly decreased during treatment and remained so six months after treatment in both groups. Psychological well-being significantly improved during therapy and at follow-up visits in both groups. Mood improved significantly in the electro-acupuncture treated group. In conclusion psychological well-being improved in women with breast cancer randomized to treatment with either AR or EA for vasomotor symptoms and we therefore suggest that further studies should be performed in order to evaluate and develop these alternative therapies.