Fear of childbirth is a predisposing factor for emergency and elective CS even after psychological counseling. Maximal effort is necessary to avoid traumatizing deliveries and negative experiences, especially for nulliparous women.

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We have shown that female physicians differ from their male colleagues in their attitudes toward providing CS on maternal request. Female physicians were more reluctant than males to provide CS on maternal request.

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Short running title: Attitudes towards mode of delivery2 Attitudes towards mode of delivery 2 Abstract Objective: To investigate midwives' attitudes and opinions on mode of delivery Design: Exploratory descriptive study. Data were collected via study specific questionnaires.Setting: South-eastern Sweden.Participants: All midwives working in two counties. Findings:Regardless of age, experience and working field the midwives considered a reasonable caesarean section (CS) rate to be around 11.5 %. None of the participants thought that the CS rate was too low. Midwives younger than 50 years of age tended to consider the current rate of CS to be too high (p = 0.059). Midwives working at a delivery ward stated that they thought the current CS rate was too high compared with midwives who worked at the antenatal care clinics (ACC) (p< 0. 001).Midwives working at a ACC agreed to the statements "One should agree to a woman's right to have an elective CS" (p<0.001) and "elective CS is the best choice for a woman with fear of delivery" (p = 0.046) to a higher degree than their colleagues at the delivery wards, no matter of age or working experience. Key conclusions and implications for practice:Midwives in the ACC setting are more willing to accept CS at the woman's request and for women with fear of delivery. It is of importance that ACC caregivers and the professionals at the delivery ward increase their collaboration with one another in an attempt to reach a consensus. 3Attitudes towards mode of delivery 3

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Introduction: About 8% of the pregnant women in Sweden receive counseling for fear of childbirth (FOC) during pregnancy. Little is known about the long-term reproductive and obstetric outcomes after counseling for FOC: Therefore, the objective of this historical cohort study was to compare the long-term reproductive and obstetric outcomes in women treated for FOC in their first pregnancy to women without FOC. Material and methods:All nulliparas consecutively referred for treatment of severe FOC between 2001 and 2007 (n = 608) were compared with all other nulliparas giving birth on the same day (n = 431). Women who were not fluent in Swedish, missing a postal address, had moved out of the area, given birth at another hospital or had a late spontaneous abortion were excluded (n = 555). A total of 235 women agreed to participate in the study, 63 (39%) women in the index group and 172 (53%) in the reference group. The women were contacted by letter in 2015, ie 7-14 years after first childbirth, and asked to permit access to their medical charts from pregnancies and childbirths and to fill out a study specific questionnaire. Based on data from the medical charts and questionnaire, the mode of delivery, birth experience, obstetric complications, FOC, counseling for FOC and number of childbirths were compared in the two groups.Results: Women in the index group less often gave birth more than twice compared with the reference group (8.2% vs 22.0%, P = 0.012). We found no significant differences in complications during subsequent pregnancies and deliveries. Women in the index group more often gave birth by CS in their first (P = 0.002) and second childbirth (P = 0.001), more often had a less positive birth experience (index group NRS: median 6.0, interquartile range 6 vs reference group NRS: 7.0, interquartile range 5, P = 0.004) in their first delivery and more often received counseling for FOC (58.7% vs 12.5%, P < 0.001) in subsequent pregnancies. Women in the index group more often experienced FOC (18% vs 5.3%, P = 0.001) 7-14 years after first childbirth.Conclusions: FOC is not easily treated. Despite treatment and exposure to childbirth many women received treatment in their next pregnancy and still suffered from FOC 7-14 years after the first childbirth.