Contents lists available at ScienceDirect

Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

From experiences to expectations: A quantitative study on the fear ofchildbirth among multigravida women

Oznur Korukcua,⁎, Okan Bulutb, Kamile Kukulua

a Akdeniz University Faculty of Nursing, Department of Obstetrics and Gynecology, 07058 Antalya, TurkeybUniversity of Alberta, Department of Educational Psychology, 11210 87 Ave NW, Edmonton, AB T6G 2G5, Canada

A R T I C L E I N F O

Keywords:Childbirth fearExperiencesMidwiferyNursingParturition

A B S T R A C T

There is a strong relationship between women's previous birth experiences and their predetermined expecta-tions. Childbirth expectations play an important role in the women's response to the birthing experience andpostpartum period. The negative emotions and expectations, such as fear of childbirth, may result in negativeexperiences in subsequent childbirths. The aim of this study is to examine the relationship between previousbirth experiences and the fear of childbirth in current pregnancy. A sample of 309 healthy women with normalpregnancies was recruited for this study. A chi-square test of independence and a multinomial logistic regressionwere used to explain the association between previous birth experiences and the fear of childbirth in currentpregnancy. The level of childbirth fear that pregnant women feel appears to differ based upon their previouspregnancy experiences. Pregnant women who describe their previous births as happy and proud tend to ex-perience a moderate level of childbirth fear about their current pregnancies, whereas pregnant women whoremember their previous births as either fearful or painful have lower levels of childbirth fear. The level ofchildbirth fear tends to decrease as pregnant women have more children. Gestational week does not seem to beinfluential on the level of childbirth fear. According to the findings of this study, counterintuitively there is anegative relationship between the previous birth experience and childbirth fear. The level of childbirth fear islower for pregnant women who remember their previous births as a negative experience compared to those whoremember their previous births positively.

Introduction

Literature review

Parturition is the great transitional event in the reproductive cycleof a woman. Apart from the natural causes of apprehension and doubtin the ordinary human being, a woman who is about to have a baby issubject to fear-producing factors peculiar to the stage of pregnancy andchildbirth (Dick-Read, 2009). The fear of childbirth, which is alsoknown as tokophobia in the literature (Hofberg & Brockington, 2000),has been described as a form of anxiety caused by the forthcoming birth(Lukasse et al., 2014). From a very early age, girls become aware of theaccepted teaching that having a baby is a dangerous and painful pro-cedure (Rouhe, Salmela-Aro, Halmesmäki, & Saisto, 2009).

There is a link between women's upcoming birth experiences andtheir predetermined expectations (Hauck, Fenwick, Downie, & Butt,2007). Parity is one of the most important factors that can influence thecontents of fear in childbirth process (Størksen, Garthus-Niegel,

Vangen, & Eberhard-Gran, 2013). Worries about the health of the baby,fear of losing the baby, fear of intolerable pain during labour, and fearof prolonged labour are the most common reasons of fear among pri-migravida women (Kızılırmak & Başer, 2016; Smarandache, Kim, Bohr,& Tamim, 2016). In contrast, childbirth fear among multiparous womenis often based on their previous birth experiences, such as the fear ofobstetric injuries during labour, loss of control, insufficient support, andan inability to cope with labour (Eriksson, Jansson, & Hamberg, 2006;Hauck et al., 2007; Størksen et al., 2013). On the other hand, owningand believing in birth as a natural event, satisfaction with the birthprocess and outcome, and involvement and participation in the birthingexperience are the important effects of positive birth attitudes for bothprimigravida and multigravida women (Hauck et al., 2007). Sluijs,Cleiren, Scherjon, and Wijma (2015) stated that women with childbirthfear in pre-partum tend to have higher levels of childbirth fear in post-partum, regardless of what obstetric complications they had to copewith. Women who suffer from severe childbirth fear typically needprofessional support for a healthy transition to motherhood.

https://doi.org/10.1016/j.apnu.2018.11.002Received 3 April 2018; Received in revised form 14 July 2018; Accepted 9 November 2018

⁎ Corresponding author.E-mail address: [email protected] (O. Korukcu).

Archives of Psychiatric Nursing 33 (2019) 248–253

0883-9417/ © 2018 Elsevier Inc. All rights reserved.

T

There is a strong relationship between the fear of childbirth andnegative birth outcomes. They both affect maternal psychologicalwellbeing, adaptation to motherhood, lower self-rated health, persis-tent memory of pain, and the quality of the mother's relationship withthe infant (Pazzagli et al., 2015; Smarandache et al., 2016). Størksenet al. (2013) found that the association between a previous negativebirth experience and childbirth fear was greater than the associationbetween previous obstetric complications and childbirth fear. Ac-cording to the results of their study, women who had experienced ob-stetric complications were more likely to have had a negative overallbirth experience and to develop a fear of childbirth; however, the ma-jority of women who experienced obstetric complications did not havea negative overall birth experience and did not develop a fear ofchildbirth (Størksen et al., 2013). A woman's birth experience can in-fluence her physical and mental well-being long after the birth of herchild (Niebler, Documét, Chaves-Gnecco, & Guadamuz, 2016). Fur-thermore, a negative birth experience has been shown to be associatedwith prolonged labour and elective cesarean section (Saisto &Halmesmäki, 2003; Smarandache et al., 2016).

Childbirth is one of the most important developmental transitions ina woman's life (Korukcu, Bulut, & Kukulu, 2016). To date, there hasbeen limited research about the effects of previous childbirth experi-ences on Turkish women's fear of childbirth during their current preg-nancies. Therefore, this study aims to examine the effects of previousbirth experience(s) of Turkish women on the fear of childbirth in cur-rent pregnancy. The findings of this study will provide psychosomaticevidence about the effects of previous birth experiences on the fear ofchildbirth in current pregnancy and help pregnant women understandthe causes of their childbirth fear during their transition to motherhoodprocess. In addition, the findings of this study will be helpful forhealthcare practitioners in promoting positive attitudes towards child-birth among pregnant women.

Theoretical framework

The Mercer's Maternal Role Attainment Theory, which is a client-oriented theory that adapts to each mothers' individual needs, was usedin the theoretical framework of this study to determine the effect ofprevious birth experiences on the level of childbirth fear in currentpregnancy. Mercer (2004) states that the transition-to-motherhoodprocess emerges with each newborn child. This view is the startingpoint for planning the current research.

Reva Rubin first developed the theory on maternal identity and roleattainment in 1967, which was taken and expanded upon by Mercer(Mercer, 2004; Noseff, 2014). Following that theory, the midwife's ornurse's role is seen as helping women adapt to the “maternal role”(Hung, Yu, Chang, & Stocker, 2011). The philosophy of this perspectivelocates the pregnant woman at the centre of the process and placesmidwives or nurses in an ideal position to draw upon the concept ofmaternal representations in order to support not only a woman's phy-sical transition to motherhood, but also her psychological transition tomotherhood (Meighan, 2013; Mercer, 2004). In the light of this theory,researchers wanted to pay attention to the psychosocial health ofmultiparous women in transition to motherhood process. Every birthjourney is unique and maternal birth experiences, expectations, andperceptions may affect a woman's subsequent pregnancies (Korukcuet al., 2016). Therefore, this study will seek for evidence of the influ-ence of past experience of multiparous women on future pregnanciesand level of fear of childbirth.

Methods

Study population

A sample of 309 healthy women with normal pregnancies was re-cruited in this study. Data were collected from pregnant women

through a paper-and-pencil survey and face-to-face interviews whenthey were attending the routine scan at the Antalya Training andResearch Hospital between June and December 2015. The followingselection criteria were used to recruit the participants of this study: (1)being a multigravida; (2) visiting to the Antalya Training and ResearchHospital for routine controls; (3) gestational ages of between 28 and40weeks with a healthy baby; (4) being 18 years or older; (5) having nopsychiatric or chronic disease; and (6) reading, writing, speaking, andunderstanding Turkish proficiently.

Instruments

The fear of childbirth during pregnancy was measured by the WijmaDelivery Expectancy/Experience Questionnaire – version A (WDEQ-A).The W-DEQ-A is a 33-item questionnaire, with each item being scoredas ‘not at all’ (0) to ‘extremely’ (5) (Wijma, Wijma, & Zar, 1998). Inaddition to the items in the W-DEQ-A, each participant responded to aset of demographic questions about age, occupation, socioeconomicstatus, education, and obstetric history and parity. Coefficient alphareliability coefficient of the W-DEQ-A was 0.88 for primigravida womenand 0.90 for multiparous pregnant women in a validity and reliabilitystudy conducted by Korukcu, Kukulu, and Firat (2012). In this study,the reliability of the WDEQ-A was 0.84, suggesting a high level of re-liability for the instrument (Korukcu, Fırat, & Kukulu, 2010).

The total scores in the WDEQ-A can be computed by summing upindividual item scores for each participant. This process results in aminimum score of zero and a maximum score of 165. A higher scoreindicates a more intense fear of childbirth. To place all of the items inthe same direction, the positively worded items (item 2, 3, 6, 7, 8, 11,12, 15, 19, 20, 24, 25, 27, 31) need to be reversed coded before thecalculation of the participating women's total score in the WDEQ-A(Wijma et al., 1998).

Ethical considerations

A written permission letter from the Head Physician's Office in theAntalya Training and Research Hospital was obtained for the study. TheAntalya Training and Research Hospital Scientific Research AssessmentBoard reviewed the proposed study and provided ethics approval forthe implementation of the study. The objective of the study was ex-plained to the pregnant women who were eligible to participate in thestudy, and the written consents were obtained from those who acceptedto take part in the study.

Data analysis

The analysis of the data began with the calculation of the partici-pants' scores in the WDEQ-A. Fig. 1 shows that the WDEQ-A scoresobtained from the participants of this study were normally distributed(M=68.26, SD=19.24). Next, the W-DEQ-A total scores were used tocategorize pregnant women based on the level of fear that they feelabout their current pregnancy as follows: zero to 60 points indicatinglow fear of childbirth, 61 points to 84 points indicating moderate fear ofchildbirth, and 85 points or above indicating severe fear of childbirth(Korukcu et al., 2010; Nieminen et al., 2017). Table 1 shows a demo-graphic summary of the participants in the sample of this study by theirlevel of fear based on the WDEQ-A scores.

The categorization of the WDEQ-A total scores as low, moderate,and high was necessary because (1) the categorical scale of WDEQ-Areflects more meaningful differences between pregnant women than thecontinuous scores from WDEQ-A; (2) regression-based analyses basedon continuous WDEQ-A scores were not feasible due to the lack ofempirical evidence suggesting a linear relationship between the fear ofchildbirth and how previous pregnancy experiences are remembered(i.e., proudly, happily, in pain, or in fear); and (3) categorical dataanalysis was a more suitable option for identifying the relationship

O. Korukcu et al. Archives of Psychiatric Nursing 33 (2019) 248–253

249

between childbirth fear and previous experiences for pregnant womenwith severe childbirth fear as the size of this group was quite smallcompared to the rest of the sample (see Fig. 1).

To examine the relationship between the pregnant women's level offear (i.e., low, medium, or high) regarding their current pregnancy andhow they remember their previous pregnancy experiences (i.e.,proudly, happily, in pain, or in fear), two statistical procedures wereimplemented. The participating women's level of fear based on the W-DEQ-A scores and their responses to the question of how they re-member their previous childbirth experiences were used as the de-pendent and independent variables, respectively. First, a chi-square testof independence was used to examine whether the two categoricalvariables are significantly associated with each other. Second, given thestatistically significant association, a multinomial logistic regressionwas used to predict the level of fear for current pregnancy (dependentvariable) using the perception of past pregnancy experiences (in-dependent variable). In the multinomial logistic regression model, the

number of prior pregnancies was included as a covariate to control forits effects on the level of childbirth fear.

Results

Fig. 2 shows the percentages of the pregnant women by the twovariables used in this study (i.e., the level of childbirth fear and therecall of previous pregnancies). Most of the participants who remembertheir past pregnancy experiences either happily or proudly indicated amedium level of fear regarding their current pregnancy. Unlike theseparticipants, the participants who remember their past pregnancy ex-periences as either fearful or painful mostly indicated either low ormedium levels of fear about their current pregnancy.

Table 1 shows that 30.4% of multiparous pregnant women indicatedlow-level childbirth fear, 19.1% of them indicated high-level childbirthfear; and the majority of the participants (50.5%) indicated moderate-level childbirth fear. Most pregnant women who have only one childindicated moderate fear of birth, whereas pregnant women with 2 andmore children indicated low-level birth fear about their current preg-nancy. This finding suggests that the level of childbirth fear tends todecrease as pregnant women have more children. Finally, gestationalweek does not seem to be influential on the level of fear of childbirth.

To test the strength of the association, a chi-square test of in-dependence was conducted. The result of the chi-square test showedthat there was a statistically significant association between the level offear that pregnant women feel about their current pregnancy and theirpast pregnancy experiences, χ2(26)= 21.068, p < .05. This findingsuggests that pregnant women's level of childbirth fear tends to varydepending on their past pregnancy experiences. The Spearman corre-lation between the level of fear about current pregnancy and their pastpregnancy experiences indicated a negative relationship (rs=−0.17,p < .05). In addition, Cramer's V, which tests the strength of associa-tion between categorical or ordinal variables, indicated that thestrength of association between the level of fear for current pregnancyand feelings about previous pregnancy/birth experiences was moderate(V= 0.185, p < .002).

Next, a multinomial logistic regression model was used to predictthe effects of previous pregnancy experiences on the level of childbirthfear for the current pregnancy. The “medium” level fear was selected asthe baseline (i.e., reference) category in the dependent variable. That is,a positive regression coefficient for previous pregnancy experienceswould suggest that the log odds of being in the low-level fear or high-level fear categories is higher than the log odds of being in the medium-level fear category. In addition, the “in pain” category was selected asthe baseline category in the independent variable. That is, the estimated

Fig. 1. Distribution of the total scores in WDEQ-A.

Table 1Demographic summary of the participants in the study.

Demographic variables Level of fear

Low Medium High

N % N % N %

Age 18–19 0 0 17 65.4 9 34.620–24 24 22.4 65 60.8 18 16.825–29 31 32.0 50 51.5 16 16.530–34 20 44.4 18 40.0 7 15.635–39 15 50.0 6 20.0 9 30.040–44 4 100 0 0 0 045 or older 0 0 0 0 0 0

Education Primary school 41 33.6 57 46.7 24 19.7Middle school 26 43.3 20 33.3 14 23.4High school 19 19.4 65 66.3 14 14.3College degree 8 29.6 13 48.1 6 22.3Graduate degree 0 0 0 0 0 0Illiterate 0 0 1 50.0 1 50.0

Number of children 1 51 23.0 129 58.1 42 18.92 31 44.3 25 35.7 14 20.03 10 71.4 1 7.1 3 21.54 1 50.0 1 50.0 0 05 1 100 0 0 0 06 0 0 0 0 0 0

Duration of pregnancy 30 weeks or less 30 31.6 44 46.3 21 22.131–34weeks 12 16.9 42 59.2 17 23.935–38weeks 26 44.1 24 40.7 9 15.2> 38weeks 26 31.0 46 54.8 12 14.2

Total 94 30.4 156 50.5 59 19.1

Fig. 2. Percentages of pregnant women by the level of childbirth fear and howthey remember their previous pregnancy.

O. Korukcu et al. Archives of Psychiatric Nursing 33 (2019) 248–253

250

effects for the other categories (happily, proudly, or in fear) would berelative to the “in pain” category.

Table 2 shows the results of the multinomial logistic regressionanalyses. The results indicated that the log odds of having a “low” levelof fear vs. a “medium” level of fear decrease if the pregnant women'sprevious experiences change from “in pain” to “happily” or “proudly”.That is, pregnant women who remember their previous pregnanciespositively (i.e., either happily or proudly) are more likely to have themedium level of birth fear than the low level of birth fear. There was nosignificant effect of moving from “in pain” category to “in fear” on thelikelihood of being in the low fear category vs. the medium fear cate-gory. The results were slightly different for the comparison of “high”fear against “medium” fear. As pregnant women's previous pregnancyexperiences change from “in pain” to “happily”, the log odds of havinga “low” level of fear vs. a “medium” level of fear decrease. That is,pregnant women who describe their previous pregnancy as a happyexperience are more likely to have the medium-level fear than the low-level fear. Unlike the findings for the low-level fear, changing from “inpain” to “proudly” in previous pregnancy experiences does not appearto have a significant impact. Similarly, the “in fear” category was notstatistically influential on the log odds of having a high level of fear vs.a low level of fear.

Discussion

Previous studies reported that the state of experiencing fear ofchildbirth in current pregnancies of multiparous women is related towhat they have experienced before (Sluijs et al., 2015). Severe child-birth fear can be experienced by pregnant women because of theirprevious birth experiences, and these women can encounter birthtrauma in their future pregnancies (Nilsson, Bondas, & Lundgren,2010). Multiparous pregnant women with negative birth experiencestend to remember their births as fearful and they express negativefeelings about their previous births (Fenwick, Toohill, Creedy, Smith, &Gamble, 2015; Nilsson et al., 2010). Negative birth experiences also areassociated with less fulfilling, being less satisfied with birth and re-porting less emotional wellbeing after birth in future pregnancies(Turkstra et al., 2017). This notion necessitated the planning of thecurrent study.

In this study, 30.4% of multiparous pregnancies were in the lowbirth fear category, 50.5% of them were in the medium birth fear ca-tegory, and 19.1% were in the high birth fear category. Furthermore,most of the pregnant women who had severe birth fear about theircurrent pregnancy were 18–19 years old. In the literature, it has beenspecified that young mother age is an important factor that may lead toan increase in the level of childbirth fear (Rouhe et al., 2009; Størksenet al., 2013; Räisänen et al., 2014; Nieminen et al., 2017). Our findings

are aligned with the existing literature about the relationship betweenage and the level of birth fear. Being a mother adds a social value to awoman in the Turkish culture, and birth gives the woman a newidentity and a social status among her family members, relatives,friends, and the community (Korukcu et al., 2016). The results of thestudy can be explained with opinions of Turkish women about child-birth. Even if mothers had negative birth experiences, they might dis-regard their bad memories and meet their future pregnancy with hap-piness and gratefulness. Furthermore, Mercer (2006) stated that thetransition-to-motherhood process emerges with each newborn child.Mothers' previous birth experience can increase self-confidence andability to overcome a difficult situation, such as the birth (Korukcuet al., 2016). New roles and responsibilities after childbirth may con-tribute to the psychological maturation and growth of mothers.

This study also indicated that pregnant women who experienced ahigh level of birth fear in their previous pregnancies are more realisticin their future pregnancies and know what to expect from their births(Räisänen et al., 2014; Fenwick et al., 2015). Størksen et al. (2013)argued that pregnant women who remember their previous births asfearful or painful might struggle with coping with issues in their futurepregnancies. The results of the work done by Fenwick et al. (2015) alsosupport this claim. Some of the pregnant women who had negativeexperiences in their previous births appear to be stronger in their cur-rent pregnancies and they have a longer-term experience that can allowthem coping with the problems of the pregnancy (Räisänen et al., 2014;Fenwick et al., 2015). Unlike this finding, this study showed that thelevel of childbirth fear experienced by pregnant women who remembertheir past births negatively was lower than those who remember theirpast births positively.

A large-scale study with 6870 pregnant women from Sweden,Norway, Denmark, Belgium, Iceland, and Estonia showed that multi-gravida women with negative birth experiences are five times morelikely to have childbirth fear than pregnant women who had normalpregnancies (Lukasse et al., 2014). On the other hand, there are otherstudies that suggest the previous birth experiences of multiparouswomen have no effect on the level of childbirth fear in the currentpregnancy (Fenwick et al., 2015; Toohill, Fenwick, Gamble, & Creedy,2014). In our study, it has been shown that most of the pregnant womenwho remember their previous births happily or proudly have a medium-level birth fear, whereas those who remember their previous births infear or in pain have a lower level of birth fear (see Fig. 2). According tothe results of the study, it was determined that the negative experienceof past births did not cause birth fear in their present pregnancy. Giventhat each pregnancy is considered unique, the causes of childbirth fearof multiparous women can be different from each other, and thepregnancy can lead to different experiences for multiparous women(Fenwick et al., 2015).

There is a common belief that multiparous women would havedifferent expectations because of their previous experiences of givingbirth. However, previous studies surprisingly indicated no significantdifferences in the frequency of different expectations between nulli-parous and mulitparous women except for the variables of ‘body controlin labour’ and ‘control of health decisions’ (Ayers & Pickering, 2005;Fenwick et al., 2015; Gibbins & Thomson, 2001; Toohill et al., 2014). Inour study, we found that the level of childbirth fear experienced bymultiparous pregnant women who remember their past births nega-tively is lower than those who remember their past births positively.Along with their expectations of childbirth, muliparous women candevelop feelings about how they will cope with labour (Gibbins &Thomson, 2001). However, each childbirth is unique and over-gen-eralizations about childbirth based on the judgments about past ex-periences should be avoided. A meeting with the midwife who providedcare in labour can help women fully understand the events of labourand birth and to help either prevent or identify adverse emotionaloutcomes (Gibbins & Thomson, 2001). Multiparous pregnant womenshould clearly talk to their midwives and nurses about the excitement,

Table 2Multinomial logistic regression results.

Level of fear β S.E. exp(β)⁎⁎

Low fear Intercept 0.057 0.239Happily −1.504⁎ 0.460 0.222Proudly −0.973⁎ 0.348 0.378In fear −0.221 0.351 0.801

High fear Intercept −0.391 0.270Happily −1.526⁎ 0.270 0.217Proudly 0.672 0.379 0.511In fear −0.621 0.432 0.538

Note: Level of fear was determined based on the WDEQ-A total scores as:low=0 to 60 points; moderate= 61 to 84 points; severe= 85 points or above.“In pain” was chosen as the reference category in previous childbirth experi-ences (happily, proudly, in fear, in pain).

⁎ p < .05.⁎⁎ exp is the exponential of β to transform the regression coefficient to an

odds ratio.

O. Korukcu et al. Archives of Psychiatric Nursing 33 (2019) 248–253

251

fear, and anticipation of their new pregnancy. In addition, they shouldbe aware of the effect of past experiences on coping processes.

It is an important midwifery/nursing duty to identify factors thatmake multiparous women feel confident to enable women's experiencesof childbirth to be satisfying, fulfilling and positive (Fenwick et al.,2015; Gibbins & Thomson, 2001). The simple act of inviting pregnantor postpartum women to talk about their childbirth expectations orexperiences is, for most of them, already therapeutic in itself (VanBussel, Spitz, & Demyttenaere, 2010). Given that past experiencespredict expectations, the development of optimistic expectations maybe used as a prevention strategy to reduce negative outcomes (VanBussel et al., 2010). Healthcare professions should investigate post-natally how women feel about their experiences (Gibbins & Thomson,2001).

Implication for future practice

This study has several implications for birth practitioners andwomen about the effects of past experiences on future pregnancies inmultiparous women. This study indicated that negative childbirth ex-periences in the past had led to lower levels of childbirth fear in nextpregnancies among multiparous women. This finding could imply twopossibilities: either expectations are too optimistic, or the providedantenatal care is of good quality. However, it is not possible to tell fromour data whether this is due to the type of care provider. Thus, furtherresearch is necessary to find out which factors are crucial, and whetherit is a matter of culture or social structure.

Mercer (2004) emphasized that nurses and midwives are the mostcommunicative people with mothers in maternity circles, and that theyhave an important role to play in protecting the health of the mothersand babies. Birth practitioners should be encouraged to listen towomen, validate their feelings on labour pain, and support them to thebest of their abilities. Exploring multiparous women's birth experienceson the level of childbirth fear in current pregnancy is important to gaina better understanding of childbearing multiparous women's care needsand necessary for women-centred care. This study will remind nursesand midwives that each pregnancy is unique, and thus, deserves a newstarting point for multiparous women. Furthermore, the results of thisstudy will help nurses and midwives to understand the previous birthexperiences of multiparous mothers on the current birth expectationsand to plan women-centred nursing/midwifery care.

Limitations

The limitations of our study should be addressed. One limitationwas that the study was conducted at a single centre and the samplegroup was small. As in similar research studies, the study sample wascomposed only of those women willing to take part in a research trial.The study did not include women who do not speak and write Turkish.Because of the sample size, the results cannot be representative of theentire Turkish population. This will also affect the generalizability ofthe results. Furthermore, in order to ensure a homogenous sample, andtaking into account that the experiences during the process of transitionto motherhood vary in each pregnancy, only multiparous were includedin the study.

Conclusion

The exploration of women's experiences and expectations of child-birth, along with the investigation of how they prepare for childbirth, isimportant to help pregnant women better prepare for labour. Previousnegative birth experiences may lead to some negative feelings – such asfear, anxiety, posttraumatic stress disorders, depressive symptoms,loneliness, anger, grief, decreased belief in ability to deliver, and re-duced reliance on caregivers (Nilsson et al., 2010). In conclusion,contrary to these findings, this study suggests that the level of childbirth

fear experienced by those who remember their previous births nega-tively is lower than the level of childbirth fear experienced by thosewho remember their previous births positively. Learning how to copewith labour pain and overcoming the fear of obscurity about birthmight improve multiparous women's psychological wellbeing andchildbirth fear in current pregnancy, even when they have negativebirth experiences (Nilsson et al., 2010). Furthermore, the desire ofpregnancy might be more important than negative birth experiences inforgetting about negative memories and preparing for a new pregnancy(Poggi, Goutaudier, Séjourné, & Chabrol, 2018). Midwives should beaware about pregnant women who experienced a negative birth in theirprevious pregnancies might be more realistic in their future pregnanciesand know what to expect from their births. In many cultures, child-bearing is viewed as the meaning of life and being a mother is the mostimportant role acquisition for a woman.

In conclusion, women's previous birth experiences may influencetheir future pregnancies. Childbirth fear can persist through the post-partum period and health care professions need to be alert to addressingthis through sensitive discussions with women about the birthing ex-perience and their thoughts concerning future births. In Turkey, there isa need for studies that would enable the standardization of care servicesand the establishment routine psychosocial health assessment forperinatal mental health of women. The results of present study mighthelp to improve of awareness of health care professions about the ef-fects of past birth experiences on future pregnancy and psychologicalwellbeing of women.

Conflict of interest

No potential conflict of interest was reported by the authors.

Acknowledgment

This study was supported by The Scientific Research Projects Unit ofAkdeniz University, Antalya, Turkey.

References

Ayers, S., & Pickering, A. D. (2005). Women's expectations and experience of birth.Psychology & Health, 20(1), 79–92.

Dick-Read, G. (2009). Childbirth without fear. London: Pinter & Martin Ltd.Eriksson, C., Jansson, L., & Hamberg, K. (2006). Women's experiences of intense fear

related to childbirth investigated in a Swedish qualitative study. Midwifery, 22(3),240–248.

Fenwick, J., Toohill, J., Creedy, D. K., Smith, J., & Gamble, J. (2015). Sources, responsesand moderators of childbirth fear in Australian women: A qualitative investigation.Midwifery, 31(1), 239–246.

Gibbins, J., & Thomson, A. M. (2001). Women's expectations and experiences of child-birth. Midwifery, 17(4), 302–313.

Hauck, Y., Fenwick, J., Downie, J., & Butt, J. (2007). The influence of childbirth ex-pectations on Western Australian women's perceptions of their birth experience.Midwifery, 23(3), 235–247.

Hofberg, K., & Brockington, I. F. (2000). Tokophobia: An unreasoning dread of childbirth:A series of 26 cases. The British Journal of Psychiatry, 176(1), 83–85.

Hung, C. H., Yu, C. Y., Chang, S. J., & Stocker, J. (2011). Postpartum psychosocialchanges among experienced and inexperienced mothers in Taiwan. Journal ofTranscultural Nursing, 22, 217–224.

Kızılırmak, A., & Başer, M. (2016). The effect of education given to primigravida womenon fear of childbirth. Applied Nursing Research, 29, 19–24.

Korukcu, O., Bulut, O., & Kukulu, K. (2016). Psychometric evaluation of the Wijma de-livery expectancy/experience questionnaire version B. Health Care for WomenInternational, 37(5), 550–567.

Korukcu, O., Fırat, M. Z., & Kukulu, K. (2010). Relationship between fear of childbirthand anxiety among Turkish pregnant women. Procedia-Social and Behavioral Sciences,5, 467–470.

Korukcu, O., Kukulu, K., & Firat, M. Z. (2012). The reliability and validity of the Turkishversion of the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) withpregnant women. Journal of Psychiatric and Mental Health Nursing, 19(3), 193–202.

Lukasse, M., Schei, B., Ryding, E. L., & Bidens Study Group (2014). Prevalence and as-sociated factors of fear of childbirth in six European countries. Sexual & ReproductiveHealthcare, 5(3), 99–106.

Meighan, M. (2013). Mercer's becoming a mother theory in nursing practice. NursingTheory-E-Book: Utilization & application. New York: Mosby.

Mercer, R. T. (2004). Becoming a mother versus maternal role attainment. Journal of

O. Korukcu et al. Archives of Psychiatric Nursing 33 (2019) 248–253

252

Nursing Scholarship, 36, 226–232.Mercer, R. T. (2006). Nursing support of the process of becoming a mother. Journal of

Obstetric, Gynecologic & Neonatal Nursing, 35(5), 649–651.Niebler, M., Documét, P. I., Chaves-Gnecco, D., & Guadamuz, T. E. (2016). Birth ex-

periences of immigrant Latina women in a new growth community. Journal of Racialand Ethnic Health Disparities, 3(3), 466–472.

Nieminen, K., Wijma, K., Johansson, S., Kinberger, E. K., Ryding, E. L., Andersson, G., …Wijma, B. (2017). Severe fear of childbirth indicates high perinatal costs for Swedishwomen giving birth to their first child. Acta Obstetricia et Gynecologica Scandinavica,96(4), 438–446.

Nilsson, C., Bondas, T., & Lundgren, I. (2010). Previous birth experience in women withintense fear of childbirth. Journal of Obstetric, Gynecologic & Neonatal Nursing, 39(3),298–309.

Noseff, J. (2014). Theory using and application paper: Maternal role attainment.International Journal of Childbirth Education, 29, 58–61.

Pazzagli, C., Laghezza, L., Capurso, M., Sommella, C., Lelli, F., & Mazzeschi, C. (2015).Antecedents and consequences of fear of childbirth in nulliparous and parous women.Infant Mental Health Journal, 36(1), 62–74.

Poggi, L., Goutaudier, N., Séjourné, N., & Chabrol, H. (2018). When fear of childbirth ispathological: The fear continuum. Maternal and Child Health Journal, 22(5), 772–778.

Räisänen, S., Lehto, S. M., Nielsen, H. S., Gissler, M., Kramer, M. R., & Heinonen, S.(2014). Fear of childbirth in nulliparous and multiparous women: A population-basedanalysis of all singleton births in Finland in 1997–2010. BJOG: An InternationalJournal of Obstetrics & Gynaecology, 121(8), 965–970.

Rouhe, H., Salmela-Aro, K., Halmesmäki, E., & Saisto, T. (2009). Fear of childbirth ac-cording to parity, gestational age, and obstetric history. BJOG: An International

Journal of Obstetrics & Gynaecology, 116(1), 67–73.Saisto, T., & Halmesmäki, E. (2003). Fear of childbirth: A neglected dilemma. Acta

Obstetricia et Gynecologica Scandinavica, 82(3), 201–208.Sluijs, A. M., Cleiren, M. P., Scherjon, S. A., & Wijma, K. (2015). Does fear of childbirth or

family history affect whether pregnant Dutch women prefer a home-or hospital birth?Midwifery, 31(12), 1143–1148.

Smarandache, A., Kim, T. H., Bohr, Y., & Tamim, H. (2016). Predictors of a negativelabour and birth experience based on a national survey of Canadian women. BMCPregnancy and Childbirth, 16(1), 114.

Størksen, H. T., Garthus-Niegel, S., Vangen, S., & Eberhard-Gran, M. (2013). The impactof previous birth experiences on maternal fear of childbirth. Acta Obstetricia etGynecologica Scandinavica, 92(3), 318–324.

Toohill, J., Fenwick, J., Gamble, J., & Creedy, D. K. (2014). Prevalence of childbirth fearin an Australian sample of pregnant women. BMC Pregnancy and Childbirth, 14(1),275.

Turkstra, E., Mihala, G., Scuffham, P. A., Creedy, D. K., Gamble, J., Toohill, J., & Fenwick,J. (2017). An economic evaluation alongside a randomised controlled trial on psycho-education counselling intervention offered by midwives to address women's fear ofchildbirth in Australia. Sexual & Reproductive Healthcare, 11(1–6).

Van Bussel, J., Spitz, B., & Demyttenaere, K. (2010). Childbirth expectations and ex-periences and associations with mothers' attitudes to pregnancy, the child and mo-therhood. Journal of Reproductive and Infant Psychology, 28(2), 143–160.

Wijma, K., Wijma, B., & Zar, M. (1998). Psychometric aspects of the W-DEQ; a newquestionnaire for the measurement of fear of childbirth. Journal of PsychosomaticObstetrics and Gynecology, 19(2), 84–97.

O. Korukcu et al. Archives of Psychiatric Nursing 33 (2019) 248–253

253