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Women’s fear of childbirth and depressive symptoms before and after birth: Studies on the magnitude, challenges, and coping strategies in Pwani region, Tanzania
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Description
Abstract [en]

Most women experience fear of childbirth (FoB) and depressive symptoms (DS), which have been associated with adverse obstetric outcomes. Such adverse effects are rarely screened in clinical practice, and knowledge of magnitude, associated factors, challenges, and coping strategies is lacking in Tanzania. This thesis aimed to assess the magnitude, challenges, and coping strategies regarding women's fear of childbirth and depressive symptoms before and after childbirth.

A mixed-method study was carried out in the Pwani region, Tanzania. A longitudinal study was performed to establish psychometric properties of W-DEQ-A and W-DEQ-B (Paper I), prevalence and predictors of FoB and DS during pregnancy (Paper II), and patterns and predictors of FoB and DS from pregnancy and postpartum (Paper III). Six hundred ninety-four pregnant women were recruited, and 625 completed the study. Individual interviews with women (n = 13) and traditional birth attendants (n = 3) and focus group discussions with women (n = 5), men (n = 2), and nurse-midwives (n = 4) were conducted to explore barriers, support, and coping strategies for overcoming FoB (Paper IV). 

Factor analysis for W-DEQ revealed seven factors with 29 items with acceptable indices. Both versions of W-DEQ had good internal consistency.

The prevalence rates of FoB decreased from 16.2% during pregnancy to 13.9% after childbirth, while DS reduced significantly from 18.2% to 8.5% (p < 0.001). Some women had persistent FoB (6.4%) or DS (4.3%). Pregnant women above 30 years old, with informal education, and/or nulliparous were more likely to have FoB and DS. Giving birth by cesarean section and spending more than 12 hours at a health facility from admission to birth were associated with postnatal FoB. Furthermore, giving birth to an ill or dead baby was a predictor for postpartum DS. 

In coping with FoB, three themes were identified: (i) perceived barriers to overcoming FoB, (ii) individual strength, family, community, and friendly healthcare facilities as proposed sources of support, (iii) turning to a higher power, socializing, and preparation as strategies to cope with FoB.

The Kiswahili W-DEQ-A-Revised and W-DEQ-B-Revised are reliable for measuring FoB with a multifactorial structure, incorporating seven factors with 29 items. FoB and DS coexist and get reduced with time. Recognizing predictors of both conditions, barriers to overcoming FoB, support, and coping strategies will help in the early identification of women at risk and in planning for timely interventions. Standardized tools and routine screening for FoB and DS during the perinatal period are recommended.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2023. , p. 82
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1901
Keywords [en]
Fear of childbirth, depressive symptoms, W-DEQ, validity, reliability, predictors, prevalence
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:uu:diva-495668ISBN: 978-91-513-1706-9 (print)OAI: oai:DiVA.org:uu-495668DiVA, id: diva2:1733724
Public defence
2023-03-22, Sal X, University main building, Uppsala, 09:15 (English)
Opponent
Supervisors
Funder
Sida - Swedish International Development Cooperation AgencyAvailable from: 2023-02-28 Created: 2023-02-03 Last updated: 2023-02-28
List of papers
1. Fear of childbirth: validation of the Kiswahili version of Wijma delivery expectancy/experience questionnaire versions A and B in Tanzania
Open this publication in new window or tab >>Fear of childbirth: validation of the Kiswahili version of Wijma delivery expectancy/experience questionnaire versions A and B in Tanzania
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2022 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 22, article id 882Article in journal (Refereed) Published
Abstract [en]

Background: Fear of childbirth is common both before and after childbirth, often leading to complications in mother and new-born. The Wijma Delivery Expectancy/Experience Questionnaires (W-DEQ) are commonly used to measure fear of childbirth among women before (version A) and after childbirth (version B). The tools are not yet validated in the Tanzanian context. This study aimed to validate the reliability, validity, and factorial structure of their Kiswahili translations.

Methods: A longitudinal study was conducted in six public health facilities in the Pwani region, Tanzania. In all, 694 pregnant and 625 postnatal women were concurrently selected and responded to W-DEQ-A and W-DEQ-B. Validation involved: translating the English questionnaires into Kiswahili; expert rating of the relevancy of the Kiswahili versions' items; computing content validity ratio; piloting the tools; data collection; statistical analysis with reliability evaluated using Cronbach's alpha and the intraclass correlation coefficient. Tool validity was assessed using factor analysis, convergent and discriminant validity. Exploratory factor analysis and confirmatory factor analysis were conducted on data collected using W-DEQ-A and W-DEQ-B, respectively.

Results: Exploratory factor analysis revealed seven factors contributing to 50% of the total variation. Four items did not load to any factor and were deleted. The factors identified were: fear; lack of self-efficacy; lack of positive anticipation; isolation; concerns for the baby; negative emotions; lack of positive behaviour. The factors correlated differently with each other and with the total scores. Both Kiswahili versions with 33 items had good internal consistency, with Cronbach's alphas of .83 and .85, respectively. The concerns for the baby factor showed both convergent and discriminant validity. The other six factors showed some problems with convergent validity. The final model from the confirmatory factor analysis yielded 29 items with good psychometric properties (chi(2)/df = 2.26, p = < .001, RMSEA = .045, CFI = .90 and TLI = .81).

Conclusions: The Kiswahili W-DEQ-A-Revised and W-DEQ-B-Revised are reliable tools and measure fear of childbirth with a multifactorial structure, encompassing seven factors with 29 items. They are recommended for measuring fear of childbirth among pregnant and postnatal Tanzanian women. Further studies are needed to address the inconsistent convergent validity in the revised versions and assess the psychometric properties of W-DEQ-A among pregnant women across gestational ages.

Place, publisher, year, edition, pages
Springer Nature, 2022
Keywords
Fear of childbirth, Pregnancy, Postnatal, W-DEQ, Validity, Reliability, Tanzania
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-491741 (URN)10.1186/s12884-022-05134-8 (DOI)000890263000004 ()36447188 (PubMedID)
Funder
Uppsala University
Available from: 2022-12-27 Created: 2022-12-27 Last updated: 2023-02-03Bibliographically approved
2. Predictors of fear of childbirth and depressive symptoms among pregnant women: a cross-sectional survey in Pwani region, Tanzania
Open this publication in new window or tab >>Predictors of fear of childbirth and depressive symptoms among pregnant women: a cross-sectional survey in Pwani region, Tanzania
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2021 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 21, no 1, article id 704Article in journal (Refereed) Published
Abstract [en]

Background Many women experience fear of childbirth (FoB) and depressive symptoms (DS) during pregnancy, but little is known about FoB among Tanzanian women. The current study aimed to assess the prevalence of FoB and DS among pregnant women and determine predictors of each and both, focusing on sociodemographic and obstetric predictors. Methods A cross-sectional study was conducted at six health facilities in two districts in Tanzania between 2018 and 2019. In total, 694 pregnant women with gestational age between 32 and 40 weeks and expecting vaginal delivery were consecutively recruited and assessed for FoB and DS. We collected data through interviews using 6 and 4-points Likert Scale of the Wijma Delivery Expectancy Questionnaire Version A and Edinburgh Postnatal Depression Scale, respectively. Women who scored >= 66 and >= 10 were categorised as having FoB and DS, respectively. We performed multivariable logistic regression to investigate the predictors of FoB and DS. Results The prevalence rates of FoB and DS among pregnant women were 15.1 and 17.7%, respectively. FoB and DS were more likely in women aged above 30 years [Adjusted Odds Ratio (AOR) 6.29, 95%CI 1.43-27.84] and in single mothers (AOR 2.57, 95%CI 1.14-5.78). Women with secondary education and above (AOR 0.22, 95%CI 0.05-0.99) and those who had given birth previously (AOR 0.27, 95% CI 0.09-0.87) were less likely to have FoB in combination with DS Women who had previous obstetric complications, and those who did not receive any social support from male partners in previous childbirth were more likely to have FoB and DS. FoB was strongly associated with DS (AOR 3.42, 95%CI 2.12-5.53). DS only was more common in women who had inadequate income (AOR 2.35, 95%CI 1.38-3.99) or had previously experienced a perineal tear (AOR 2.32, 95%CI 1.31-4.08). Conclusions Not having a formal education, having only primary education, being aged above 30 years, being single, being nulliparous, having experienced obstetric complications, and having a lack of social support from a male partner during previous pregnancy and childbirth were predictors of FoB and DS during pregnancy. FoB and DS were strongly associated with each other. It is vital to identify at-risk women early, to offer support during pregnancy and childbirth.

Place, publisher, year, edition, pages
BioMed Central (BMC)BMC, 2021
Keywords
Fear of childbirth, Depressive symptoms, Pregnancy, Childbirth, Prevalence, Predictors, Tanzania
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-458467 (URN)10.1186/s12884-021-04169-7 (DOI)000708867300002 ()34666696 (PubMedID)
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2021-11-15 Created: 2021-11-15 Last updated: 2024-01-15Bibliographically approved
3. Patterns and predictors of fear of childbirth and depressive symptoms over time in a cohort of women in the Pwani region, Tanzania
Open this publication in new window or tab >>Patterns and predictors of fear of childbirth and depressive symptoms over time in a cohort of women in the Pwani region, Tanzania
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2022 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 17, no 11, article id e0277004Article in journal (Refereed) Published
Abstract [en]

Background: Fear of childbirth (FoB) and depressive symptoms (DS) are experienced by many women and can negatively affect women during and after pregnancy. This study assessed patterns of FoB and DS over time and associations of postpartum FoB and DS with sociodemographic and obstetric characteristics.

Methods: We conducted a longitudinal study at six health facilities in Tanzania in 2018-2019. Pregnant women were consecutively assessed for FoB and DS before and after childbirth using the Wijma Delivery Expectancy/Experience Questionnaire versions A & B and the Edinburgh antenatal and postnatal depressive scale. This paper is based on 625 women who completed participation.

Results: The prevalence rates of FoB and DS during pregnancy were 16% and 18.2%, respectively, and after childbirth, 13.9% and 8.5%. Some had FoB (6.4%) and DS (4.3%) at both timepoints. FoB was strongly associated with DS at both timepoints (p < 0.001). Both FoB (p = 0.246) and DS (p < 0.001) decreased after childbirth. Never having experienced obstetric complications decreased the odds of postpartum and persisting FoB (adjusted odds ratio (aOR) 0.44, 95% confidence interval (CI) 0.23-0.83). Giving birth by caesarean section (aOR 2.01, 95% CI 1.11-3.65) and having more than 12 hours pass between admission and childbirth increased the odds of postpartum FoB (aOR 2.07, 95% CI 1.03-4.16). Postpartum DS was more common in women with an ill child/stillbirth/early neonatal death (aOR 4.78, 95% CI 2.29-9.95). Persisting DS was more common in single (aOR 2.59, 95% CI 1.02-6.59) and women without social support from parents (aOR 0.28, 95% 0.11-0.69).

Conclusions: FoB and DS coexist and decrease over time. Identifying predictors of both conditions will aid in recognising women at risk and planning for prevention and treatment. Screening for FoB and DS before and after childbirth and offering psychological support should be considered part of routine antenatal and postnatal care. Furthermore, supporting women with previous obstetric complications is crucial. Using interviews instead of a self-administered approach might have contributed to social desirability. Also, excluding women with previous caesarean sections could underestimate FoB and DS prevalence rates.

Place, publisher, year, edition, pages
Public Library of Science (PLoS), 2022
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-495666 (URN)10.1371/journal.pone.0277004 (DOI)000925067300079 ()36327253 (PubMedID)
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2023-01-31 Created: 2023-01-31 Last updated: 2023-06-13Bibliographically approved

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