Identifying fear of childbirth in a UK population: qualitative examination of the clarity and acceptability of existing measurement tools in a small UK sample

Abstract

Background Fear of childbirth is related to but not synonymous with general anxiety, and represents a superior predictor for maternal and infant outcomes. There is a need to improve the identification and provision of support for women experiencing high fear of childbirth. However it is uncertain as to whether existing measurement tools have appropriate content validity (i.e. cover the relevant domains within the construct), practical utility, and whether they are acceptable for use with a UK population. This study aimed to (1) identify the utility and acceptability of existing measures of fear of childbirth (FOC) with a small UK sample and (2) map the content of existing measures to the key concepts of fear of childbirth established by previous research. Methods Ten pregnant women; five with high and five with low fear of childbirth participated in a cognitive interview covering four most commonly used measures of fear of childbirth: 1. The Wijma Delivery Expectancy Questionnaire (WDEQ A), 2. The Oxford Worries about Labour Scale (OWLS), 3. The Slade-Pais Expectations of Childbirth Scale – fear subscale (SPECS) and 4. The Fear of Birth scale (FOBS). Each measure was also reviewed by participants for ease and clarity of understanding and acceptability. The measures were then reviewed against the key domains identified in the fear of childbirth literature to ascertain the adequacy of content validity of each measure. Interviews were analysed using thematic analysis for each scale item. Results All measures except the FOBS, included items that either women did not understand or, if where there was understanding the meanings were inconsistent across women. All measures demonstrated limited acceptability and content validity for the specific construct of FOC. Therefore, none of the measurement tools currently used within the UK met criteria for understanding, acceptability and content validity for measurement of FOC. Conclusions Findings emphasise a need to develop a specific fear of childbirth tool with good clarity which demonstrates appropriate content validity, and that is acceptable in presentation and length for pregnant women in a UK population.

A new scale for fear of childbirth: the Fear of Childbirth Questionnaire (FCQ)

“…A distinction is made between primary tokophobia (occurring with no prior experience of giving birth) and secondary tokophobia (occurring following the experience of a prior birth; Saisto & Halmesmäki, 2003). It is estimated that approximately one in seven women experience severe FOC (O'Connell et al, 2017); however, this proportion is uncertain given limitations in existing measurement tools and methods of inferring severity (Jomeen et al, 2021;Slade et al, 2020).…”

“…Many healthcare professionals use additional measures to try to gain further meaningful information about specific pregnancy or birth-related fears. The limitations of many of these measures have been highlighted, in terms of their utility and acceptability for English speaking UK women (Jomeen et al, 2021;Nilsson et al, 2018;Richens et al, 2018;Slade et al, 2020). The appropriate development of valid UK measures has been hindered by issues like the general lack of clarity around the definition of FOC in the UK (Richens et al, 2018;Rondung et al, 2016) and the cultural sensitivity of otherwise reliable and valid measures after being translated into English (Johnson & Slade, 2002;Toohill et al, 2014).…”

“…(5) Fear of being 'done' to; this involved fears about interventions or procedures being conducted, without women being actively involved in the decision-making process (6) Fear of not having a voice in decision making; this involved fears about having preferences 'missed' during labour and birth, and not feeling listened to (7) Fear of being abandoned and alone; this involved fear about being physically alone, for example, without a birth partner or midwife, but also a sense of feeling psychologically alone (8) Fear of my body's ability to give birth; this encompassed fears relating to physically being able to give birth, including concerns about women's own body size, their baby's size or positioning and their own physical strength to cope through labour and birth (9) Fear of internal loss of control; this included fears about losing self-control throughout labour an birth (10) Terrified of birth and not knowing why; this final element encompassed a general feeling of fear, without a specific reason or cause Any measure needs to take into account women's preferences for length and style in order to maximise appropriate usage. Phase 2 of the FOCUS study (Slade et al, 2020) aimed to consider all relevant existing measures in terms of their content validity, practicality of completing the questionnaire (ease of completion, structural properties of the measure) and whether they met acceptability criteria in terms of phraseology, clarity, length and presentation. Cognitive interviews were conducted with pregnant women to review four of the most commonly used FOC measures in the UK; the WDEQ-A (Wijma et al, 1998), the Oxford Worries about Labour Scale (OWLS; Redshaw et al, 2009), the Slade-Pais Expectancy of Childbirth Scale (SPECS; Slade et al, 2016) and the Fear of Birth Scale (FOBS; Haines et al, 2011).…”

“…In terms of acceptability, the phraseology of the OWLS was viewed positively; as women felt that the language used was easy to identify with. Two items in the WDEQ-A and one item in the SPECS raised acceptability concerns, due to perceived negative phraseology (Slade et al, 2020).…”

“…None of the existing measures included items that asked about each element of FOC. Issues in the existing scales therefore extended beyond acceptability and included inadequate content validity (Slade et al, 2020).…”