Understanding fear of childbirth among underrepresented populations in the United States

Abstract

The purpose of this study was to expand our understanding of fear of childbirth (FOC) by examining the interplay between individual, provider, identity, and culture among women historically underrepresented in FOC research to develop a deeper understanding of FOC. Purposive sampling was used to recruit 22 participants into three different focus groups, each with a unique demographic makeup. The results provide evidence that people’s birth experiences and their experiences with fear surrounding childbirth are affected by many other social mechanisms, including relationships with providers, birth setting, race, class, gender, sexual orientation, and ethnicity.

Keywords

alliance childbirth fear of childbirth health disparities qualitative research

Introduction

Health disparities are large and pervasive in the United States. Explanations for group health disparities often focus on structural factors, such as differences in socioeconomic status and access to health care (Dovidio et al., 2008). Although these and other factors contribute to health disparities, bias among health care providers and perceived discrimination are increasingly receiving empirical attention as a class of stressors that could have consequences for health outcomes and for understanding the persistence of disparities (Dovidio and Fiske, 2012; Williams and Mohammed, 2009). A focus on distrust of the health care system born out of bias and negative interactions with health care providers is consistent with broader interest in the role of perceived discrimination and minority stress as determinants of social disparities in health (Alhusen et al., 2016; Almeida et al., 2018). Trust is considered to be a vital element of the therapeutic alliance between health care providers and the individuals they serve and is associated with the degree to which patients seek routine medical care, adhere to recommendations or medications, and maintain long-term relationships with providers (Roosevelt et al., 2015).

Perhaps one of the most vulnerable health care events in the United States in which a person should trust that a clinician will provide them with respectful care is the experience of childbirth. It represents the rare intersections between major physiological change, intense psychological meaning, and vulnerability as a psychosocial event. Although it is a universal transition, childbirth is significantly influenced by the broader societal context and cultural values and norms, and disrespectful care is well documented (Bassey Etowa, 2012). Fear of disrespectful behavior in institutions has been identified as a major deterrent in seeking out maternity care in hospitals, particularly among marginalized populations (Jackson et al., 2012; Sewell, 2015; Symon et al., 2010; Vedam et al., 2017).

In contrast to the trend of framing health experiences/disparities as rooted in structural issues, research on the fear of childbirth has largely framed it as an individual psychopathology. Although fear of childbirth (FOC) is recognized as a common clinical problem, no uniform definition has been established (Saisto and Halmesmaki, 2003). In general, FOC is often defined as an anxiety disorder or as a phobia manifesting as nightmares, physical complaints, concentration difficulties on work and family activities, and as a request for a cesarean section (Räisänen et al., 2014; Saisto and Halmesmaki, 2003) Fear of childbirth is likely a more intricate feeling with both individual and sociocultural patterns of contributing factors. Until recently, only three small studies had been done in the United States (Beebe et al., 2007; Bhagwanani et al., 1997; Lowe, 2000). The small study samples are largely White, affluent, well-resourced, and homogeneous populations limiting insights into health disparities. Expanding the definition and our understanding of FOC to examine the interplay between identity, provider, birth setting, and culture allows for a deeper interpretation of the origins of FOC and a richer understanding of how interventions can be structured to reduce fear and improve outcomes.

The goals of this study were to examine FOC among a diverse sample of women to explore their experiences and how interactions with health care providers and systems inform the experience of childbirth. Focusing on diverse populations provides a means to hone a critical understanding of the phenomenon by eliciting a perspective from both dominant and non-dominant groups and allows us to have a greater understanding of how psychologic mechanisms such as FOC may inform disparate outcomes.

Materials and methods

To describe fully the experience of fear of childbirth, a phenomenological study was undertaken with University of Michigan Health System Institutional Review Board approval (HUM00063722). Bronfenbrenner’s Ecological Systems Theory (EST) was chosen to guide this project to situate FOC within the complex, dynamic relationship of a person, their birthing environment, and the larger chronosystem that informs these relationships (Bronfenbrenner, 1979). EST contains four components or systems that influence a studied phenomenon, the microsystem, the mezzosystem, the exosystem, and the macrosystem. In the proposed theoretical model, the microsystem includes the individual level factors such as social support, mental health, and physiologic experience. The mezzosystem includes providers such as nurses, doulas, midwives, or physicians. The exosystem represents the setting of birth: home, birth center, or hospital. The macrosystem represents larger social structures such as racism, homophobia, sexism, historical factors, and culture.

A purposive sampling strategy was used for participant recruitment in this focus group study. Inclusion criteria were the following: (1) Any woman of childbearing age who is 18 years of age or older and (2) self-identified as having fears or worries about childbirth. Non-pregnant and nulliparous women were included in the focus groups to capture the experiences of women whose expressed fear about childbirth is so great they may avoid becoming pregnant. Deliberately, each focus group had a unique demographic makeup.

The first focus group took place at a women’s art and music festival in the Midwest that attracts primarily women who identify as a sexual minority (i.e. lesbian, bisexual, and queer). The second focus group took place at an urban health clinic that serves primarily Spanish-speaking clients in Detroit. This group was entirely Latinx-identified women who had experience with birth personally, as well as professionally as doulas or health educators within their community. The last focus group took place at a family planning and prenatal clinic in Detroit that serves predominantly Black women. All focus groups took place in English; however, a translator was present at the focus group serving primarily Spanish-speaking people in case a person presented to the group who did not feel comfortable participating in English.

All focus groups were recorded using a digital voice recording application on an iPhone. The principle investigator (PI) kept handwritten field notes in addition to the recording of the interviews. The investigators approached the interviews with the attitude of phenomenological reduction, which was maintained throughout the process of analysis. The reduction involved bracketing, which is defined as withholding prior knowledge of the phenomenon to avoid imposing any of the researcher’s ideas or interpretations upon the phenomenon (Chan et al., 2013). The introduction of the focus group was general and open ended, consistent with a phenomenological approach. Participants were given an opportunity to discuss what fear of childbirth has meant to them and what type of thoughts or ideas came to mind when they thought about birth. After FOC was discussed more generally the interviewer then probed each of the categories of the proposed model with open-ended questions to situate FOC within the larger sociocultural context. Each focus group was concluded by asking each participant to provide three “bullet points” with the “take home messages” about what fear of childbirth meant to them (Seng et al., 2004).

After the three focus groups were completed, the recordings were transcribed while reviewing written field notes to ensure that all topics discussed in the notes were audible in the recordings. The transcriptions of the focus groups were then imported into NVivo qualitative software for analysis. The theoretical model was used to develop the coding matrix apriori which was then applied to the text. After the text was condensed, the resulting meaning units were organized into categories that share commonality but are exhaustive and mutually exclusive, as much as is possible when describing emotion specific to the human experience.

Results

The described recruitment strategy resulted into three focus groups. The demographic characteristics of 22 participating women are presented in Table 1.

Table 1.

Focus group demographic information.

N = 22	Overall, N (%)	Focus group 1, N (%)	Focus group 2, N (%)	Focus group 3, N (%)
Ethnicity
White	7 (32)	5 (83)	1 (11)	1 (14)
Latina	8 (36)		8 (89)
Black	6 (27)			6 (86)
Asian	1 (5)	1 (17)
Age (years)
18–25	7 (32)	1 (17)	3 (33)	3 (43)
26–34	10 (45)	3 (50)	4 (44)	3 (43)
35–45	5 (23)	2 (33)	2 (23)	1 (14)
Household composition
Single	5 (23)		3 (33)	2 (29)
Married/partnered	14 (64)	5 (83)	5 (56)	4 (57)
Divorced	2 (8)	1 (17)	1 (11)
Separated	1 (5)			1 (14)
Education
Some high school	2 (8)		1 (11)	1 (14)
High school/GED	6 (27)		4 (43)	2 (29)
Some college	5 (23)	1 (17)	2 (23)	2 (29)
Trade/technical	1 (5)			1 (14)
Associate degree	1 (5)			1 (14)
Bachelor’s degree	4 (19)	2 (33)	2 (23)
Master’s degree	2 (8)	2 (33)
Professional degree	1 (5)	1 (17)
Employment
Employed for wages	17 (77)	5 (83)	9 (100)	3 (43)
Student	3 (14)	1 (17)		2 (28.5)
Unemployed	2 (9)			2 (28.5)
Childbearing history
Never been pregnant	3 (14)	1 (17)	2 (23)
Currently pregnant	4 (18)	1 (17)	1 (11)	2 (29)
Given birth in past 5 years	15 (68)	4 (66)	6 (66)	5 (71)
Type of health care provider utilized for care
Certified nurse midwife	8 (36)	1 (17)	2 (23)	5 (71)
Homebirth midwife	1 (5)	1 (17)
Obstetrician	12 (54)	3 (50)	7 (77)	2 (29)
Family physician	1 (5)	1 (17)

Review and analysis of the transcripts using the apriori codes developed from the model resulted in identification of themes that were linked with the various levels of analysis. Each of the themes are named and described below.

At the initiation of the discussions, participants welcomed the discussion of fear of childbirth, expressing an immense sense of relief about being asked about their fears. As one woman said “We all have those fears and they are really real and they take up so much mental energy. So much. I don’t think I ever went more than a few hours without revisiting a new fear” (Group (G) 1). Despite the universality of the fears and the recognition that some fear is a normative part of the experience, many women felt that it was not okay to express their fears to other people. “The verbalizing of the fears might make them real or I might get an answer that is worse than the fear itself” (G2).

Relational fears

Women felt vulnerable when giving birth. “I hated that feeling of being totally at the mercy of these strangers and trusting that they would treat me and my baby good” (G3). For many women, choosing who attended the birth was a key modifier of how fearful they felt. Women sought out care providers they trusted who they felt would tend to their fear or provide care in a way that made them feel safer. “I felt so loved and supported at my births with my family around” (G2). Many women discussed the desire to have women friends and family around and how the presence of someone who had been through birth before felt reassuring and comforting.

I wanted my mom and my grandma and all my aunties there even though I knew I wouldn’t be allowed to. I just felt like if I could look up and see a bunch of people who had done this that I would remember that I could do it too (G3).

Feelings of control

Feeling out of control in the process of giving birth was a fear for many women. The fear of being out of control was also wrapped up with being worried about being disrespected based on identity. “For me it is about feeling out of control and what would or could happen to my body having a baby and being treated like shit because I was a dyke.” (G1). A big theme in the group that was predominantly Black identified was the actual physical loss of control of bodily functions. Women worried about having bowel movements in front of their partners or yelling too loudly and being told to be quiet. “I remember . . . nurses sitting around talking about how so and so was acting the fool and couldn’t get a grip so then being that patient became one of my biggest fears . . . (G3).

Pain and control

The feeling of being out of control was invariably linked to fears about the pain and whether women had the strength to handle the hard work of birth.

I just didn’t think I could do it. I hate being in pain and everyone talked about birth as the most pain you ever had and I felt like maybe the pain would be so bad that I would lose my mind. (G2)

The discussion about how painful birth was became such a fear that it deterred women from actually getting pregnant. For many women, how they handled the pain and whether they chose to utilize pain medication was a fear. “Like if they can’t handle it and need to get an epidural that their mother will say they aren’t really moms because they didn’t do it without drugs and couldn’t handle the pain” (G2). While the pain of birth was a major fear for many people, other people tried to transform the experience as moving from a place of fear to a place of united triumph after the birth.

When my little girl came out and cried and the pain stopped I just felt like this little person and I had been through this dark path together and survived and how amazing is that that we did that together. (G1)

Relationships with health care providers

In addition to personal fears about their own birth experience, people in all three focus groups expressed a number of fears about their interactions with health care providers. Women expressed fears and worries about not being a “good” patient. They had a lot of expectations for themselves during the delivery and a lot of fear that they would let down their providers if they did not behave appropriately. “I was afraid I wouldn’t be a good patient and then they would talk about me” (G3). Other women were worried about being too demanding.

Like I know they’re all busy up there and so I didn’t want to go in and out of the hospital not sure if I was in labor and have my doctor come in over and over again and then have to be there forever if I’m taking too long.(G2)

Some women felt the need to represent their whole demographic so as not to give a bad name to other women. For example, a lesbian-identified woman stated the following:

We are such a small minority of patients, especially in the pregnancy world, that there is this need to live up to the expectation of being awesome parents and really good at the whole pregnancy gig or the doctor might think we aren’t doing it right and then you get into the whole do they respect me thing. (G1)

Many women translated this fear of having to live up to expectations based on their identities into choosing providers that shared their identity. “I’d imagine if you’re like me it is really both, you like them, and you share life experience with them so you can feel a little more confident about the whole birth process” (G1). And “It was really nice to just be able to talk about our identities in a way where we didn’t need to educate, we could just, you know, coexist and feel understood” (G1). For those who chose to work with providers with whom they did not share a common identity, women talked about how important it was to have a provider that was able to be open and kind and how much the attitude of their provider alleviated their fears. “Then we met her and felt like it was all going to be okay. She just exuded this kindness and acceptance and we didn’t have to explain ourselves” (G1). While all groups discussed the differences in identities between themselves and their providers, it was largely the white women who discussed seeking out alternative providers to meet their stated need to have a similar provider. This is likely indicative of a potential race difference in the experience of agency within the health care system (Doescher et al., 2000).

Women in all focus groups spoke about assumptions on the part of their health care providers that made their fears worse and increased their anxiety about the birth process. Many women talked about experiencing microaggressions from their providers that they felt came from being of a different class or race than their provider.

I know a lot of the women who have babies with those doctors use Medicaid . . . but I just knew if I could get some private insurance . . . than they would see me different and probably treat me different. I was never able to get different insurance and I still wonder if maybe they would have listened to me more when I was having all those early pains and maybe my baby girl wouldn’t have come so early. Like they would have respected what I had to say more if they thought I had more money or if I looked more like who they are. (G3)

Respectful care

The theme of being treated respectfully by their providers came up in all three groups.

The feeling of being out of control when I’m potentially naked and trusting some doctor, or you know doula or midwife or whatever, to treat you well when you are naked, out of control, in pain, and in a public space? I wanted them to respect me. I hoped they would respect me. (G3)

For many women, differences in dialects and language added into their fears that they would be respected or not.

I mean I speak English better than that doctor did but he got all slow and curt because he thought I was some young stupid girl who didn’t understand. But I understood just fine what was wrong with my baby; I had done lots of research. He just wasn’t being respectful and I didn’t like that. (G3)

An additional aspect of fear of disrespect was the fear of not being listened to by their providers. “I really love my OB but I have never felt so patronized as when she told me that I didn’t need to worry so much” (G1). This came up especially when women expressed their fears and worries about the birth process to their health care providers.

I made a joke once about now knowing how much it was going to hurt this time and I was looking for some reassurance or something and instead I felt really sort of dismissed and shamed by his answer. Like of course it is going to hurt, you’re having a baby, what did you think would happen . . .? (G3)

This feeling of dismissal was not experienced universally. Some women described being able to discuss their fears and have them be heard. “This is again why I loved our midwife. I felt like we could bring our fears to the table anytime and she would sit with them and could really hear my concerns” (G1). The feeling of being listened to extended to how women felt like their pain would be managed by their providers. One woman discussed how she chose a midwife to attend her birth because she felt like her birth plan would be accommodated.

I liked how my midwife told me once during my prenatal visit that if I didn’t want an epidural she would do the best she could to help me get through that birth without that needle in my back. She talked about how I just needed to let all the people know what I wanted and that she would help make sure that I got it, even if I forgot that I didn’t want the medicine and started asking for it she would remind me of my plans and wishes and help me see if they had changed or if I was just feeling scared. (G3)

The most distressing fear for many of the women in relation to not be listened to is whether they feel included in their own health care decisions and in the birth process. For women who do not have English as the first language, this is a poignant fear.

They just assumed because she was young and Mexican that she wouldn’t speak the language and so they didn’t feel the need to tell her things or include her and they also just assumed that she would have the baby just fine with no help because her mom was there. (G2)

This role of language and being listened to extended to women with a lower education level as well.

I don’t claim to be the smartest woman and I don’t have a bunch of degrees and school stuff but what I do know is my own body. I knew something was wrong with that baby. I just knew it. I really, really knew it and they still didn’t listen to me. (G3)

Birth setting fears

The setting in which a woman chooses to give birth can reflect a lot about her fears and worries about the process. A study in the Netherlands found that women who chose to give birth in the hospital typically had more FOC (Sluijs et al., 2019). In these focus groups, there was much discussion about giving birth at home versus in the hospital in terms of women’s own experiences as well as the experiences of their family and friends. For some women, giving birth at home felt like where they would feel safest and least afraid. The women who actually had homebirths in the focus groups were all from group 1 and were primarily well educated, partnered, and White.

See I grew up an athlete so I had lots of sport injuries as a kid and college student and was in and out of the hospital a lot and met a lot of really crummy providers with no skills. I feel like some of the pain that I have now is because they didn’t really take me all that seriously or give me good care or respect me and I hated it. (G1)

For this woman, if she was going to give birth, it was going to be in a place where she felt safe and supported by the providers that she chose to interact with. “Some neighbors of ours had the baby at home and if I wasn’t going to get it wham bam cut out all neat and clean than I sure as hell wasn’t going back to the hospital” (G1).

For many of the women in group 2, homebirth was something that they had heard about and were interested in but still had their babies in a hospital. One woman connected the experience of being afraid with planning a hospital birth.

My mama had all of us at home too in Mexico. She had some bad stories and she talks a lot about the pain but she never seemed afraid or unhappy. It seems like the women who are afraid are the ones that go to the hospital. (G2)

Some women challenged the idea that hospital birth was safe at all. “Everybody just goes to the hospital because they think they will be ‘safe’ there and then the stories are terrible and they are so unhappy” (G3).

While homebirth was the dominant narrative regarding birth site of group 1, many women in the other two focus groups felt like the hospital was the safest place to be and had fears and worries about the idea of having a baby in an out-of-hospital setting. For these women, the process of birth felt so inherently risky that, even if they did not like their providers, they still felt a hospital was the safest place to give birth. “It’s funny because I didn’t like the people at the hospital but I felt safer being there. I would be too afraid to have a baby at home without an operating room nearby” (G3). The hospital provided a network of safety for a potentially unpleasant and risky life event. “Oh man, I barely wanted to have a baby the normal way. I really wanted to have a cesarean but they don’t let you do that unless there is something wrong” (G3).

Racism, sexism, and homophobia

Many women discussed how their own cultural understanding of birth contributed to their attitudes as well as their worries.

We live in Mexican neighborhoods, we get our health care here with people we know and (who) understand us, we work with other Mexicans, our children are cared for by neighbors, so we get to be ourselves. But when you go the hospital . . . you have to meet this other world, a world that doesn’t like understand us or how we do things. (G2)

Women linked their fears about birth and pregnancy to larger social constructs of sexism, racism, and homophobia. One woman talked about how one of her biggest fears about pregnancy and birth was having her body be further on display in a world that already commodifies the female body.

Why I didn’t want to do it? . . . hmmm . . . well at the top of the list is the gendered idea of pregnancy and birth. I’m a big fat butch and so is my partner, we aren’t girly and pregnancy is so gendered and the body is so public and I’ve tried my whole life to make my body not a public commodity. (G1)

For women from a racial minority, the influence of racism contributed to their fears about pregnancy and birth.

Race absolutely matters in birth. It matters in everything. Some of it is the way the doctors treat us but I think it is also just the whole system. It’s not set up for us to understand or be able to navigate and of course that is going to make us afraid. (G3)

Women from group 3 talked a lot about the disparities in infant and maternal health and how scared they felt going into the process knowing that just by nature of being Black they and their children had a higher chance of dying during birth.

I don’t want to be one of those people that makes everything about race because I know most of it is just how people treat each other but I agree, racism affects the way we are treated in birth. How can it not with how often our babies die and only like a few people even looking at that to see why that happens? If white babies be dying people going to stand up and take notice. (G3)

Discussion

The findings from the focus groups provide insights into understanding how fear of childbirth is experienced within diverse samples of women and how those fears may lay the groundwork for health disparities. Historically, fear in pregnancy was a symptom regarded, by care providers, as a fairly unambiguous entity that could be solved by the promise of pharmacological pain relief (Adams et al., 2012; Alipour et al., 2012; Sjögren and Thomassen, 1997). However, women experience FOC as a complex phenomenon that extends far beyond typically assumed fear of the pain of childbirth or other individual level fears. Many of the individually focused themes that emerged from the focus groups reiterated themes seen in previous research, such as fear about the pain of childbirth or fear that the woman or her child may die during the birth process (Sjögren and Thomassen, 1997). However, new themes were identified and relate to the woman in the context in which she sees herself giving birth. While fears such as feeling out of control during the process or feeling vulnerable have been discussed in previous research, the strong relational component of the fears women expressed in this study have not been discussed in previous literature (Geissbuehler and Eberhard, 2009; Nieminen et al., 2009).

Women in the focus groups talked extensively about the role of their provider and how providers can ameliorate their fears and worries or make them worse. The relationship of trust and respect between a woman and her provider is a key component in informing fear of childbirth. Many women have concerns about not having a shared identity with their provider and how that lack of shared identity leads to experiences of disrespect, not being listened to, and not included in health care decisions. Women are very aware of the history of abuse of marginalized women in the health care system. They have fears that providers who do not share those identities may be more likely to perpetrate that history during the birth process.

Interactions with their providers and the desire for approval and to be “good patient” were persistent themes in all three groups. This continued attention to providers leads to a tremendous amount of fear. This is consistent with other research examining the role of socialized gender roles and childbirth where women expend an enormous amount of energy taking care of others and obeying gendered social norms about politeness (Martin, 2003). However, the internalized understandings of social structures that compel women during birth may vary tremendously by socioeconomic status, racial identity, and other cultural and personal factors (Chodorow, 1995; Kane Low, 2001).

Some of the most compelling findings from the focus groups were the discussions about social constructs of identity and how those influenced whether a woman feared the birth process or not. Grounding this work within the context of EST allowed the discussion to move beyond the interpersonal experience of FOC and into the larger social constructs that inform health care disparities and how social and contextual factors are linked to FOC in the United States. Women talked about cultural understandings of birth and how their cultural identity leads to them feeling misunderstood or disrespected in the health care setting. This extended to interpretations of sexism, racism, and homophobia and how those constructs played out during the childbirth experience.

We live on the border between two cultures and that affects our health, our work, our children. Everything. Birth just brings it out more because it combines all the things we do, our family, our bodies, everything, into one time. And when you live in a place that involves balancing two worlds, well maybe the birth is the thing that tips that balance and we fall. (G2)

Viewing women as intrapersonal units of study as opposed to deeply rooted within the culture in which they live fails to recognize the way women gain power and active control over their birthing experience within a system of care that is highly enmeshed with medicalization. We need to address not just the individual woman’s fears but also how her provider, birth setting, and society at large contribute to integration of the birth experience and her fears and worries around the process.

Limitations

Generalizability from focus groups is limited, and this may be especially true when extending the results to other minority populations. Another common limitation of focus group methodology is selection bias; most of the participations thought the location and time were convenient. Despite these limitations, focus group methodology remains a viable way to gain information that is not easily obtained through quantitative methods. Focus groups also highlight social processes in an experience as it is discussed within the group in contrast to individual interviews. The use of open-ended nature of questions allows the more salient issues to be raised in the discussion but it does not assure that all relevant issues have been addressed in the focus group discussions. Finally, all the women who participated in the focus groups identified as women, meaning that the experiences of transgender and nonbinary people were not explored.

Conclusion and clinical implications

The results of these focus groups indicate that how we assess FOC in our practice and research needs to be expanded to include things that women identify as key contributors to their fears and worries. Clinically, the results should encourage providers to reexamine their approach to pregnant people expressing fears about the childbirth experience. The general narrative for providers has been that FOC can be addressed with increased education or with increased access to pain-relieving medication. The results of these focus groups should encourage providers to explore with women how extrinsic factors, such as the patient/provider relationship, birth setting, and implicit biases, may be informing FOC.

There is evidence to support the notion that social constructs such as race, class, sexual orientation, and gender have an impact on the subjective evaluation of the experience of birth, the actual character of the birth itself, and broader health disparities. There has been little work that systematically analyzes the differences between women in terms of their attitudes, desires, and their differential access to and use of power in childbirth to construct a context for giving birth that makes them feel safe. As providers of maternity care, the opportunity for education and training in cultural humility and the role of unconscious bias represents an opportunity to expand provider awareness, knowledge, and skills which can aid them in supporting the range of individuals they care for during pregnancy and childbirth.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Lee K Roosevelt

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