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The Arts in Psychotherapy

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Research Article

Group art therapy for the management of fear of childbirthCeren Sezena, Barış Önen Ünsalverb,⁎

a Üsküdar University, Clinical Psychology Master’s Program, Istanbul, Turkeyb Üsküdar University, Istanbul, Turkey

A R T I C L E I N F O

Keywords:group art therapyfear of childbirthart therapytocophobia

A B S T R A C T

Background: Even though most pregnant women might have some concerns regarding the mode of delivery somewomen may experience a heightened fear of childbirth (FOC), which may make pregnancy a disturbing anddiscomforting experience for them. Clinical FOC leads to an increase in C-section demands and the ratio of C-section births. Therefore, management of FOC is essential for improving public health. The objective of this pilotstudy was to evaluate the efficacy of group art therapy for the management of FOC.

Methods: To understand the effectiveness of group art therapy, we designed a quantitative study. The po-pulation studied was pregnant women with subjective complaints of FOC attending an outpatient pregnancyfollow-up clinic. Effectiveness of group art therapy intervention was assessed in comparison to group psy-choeducation for FOC. The primary outcomes of the study were determined as Wijma Delivery Expectancy/Experience Questionnaire Version A (W-DEQ) scores below 37, Beck Depression Inventory (BDI) scores below 14and the Beck Anxiety Inventory (BAI) scores below 10 at the end of the 6th session for the art therapy group. Weexpected to find significant differences in the primary outcome measures between the two groups. The secondaryoutcome of the study was the difference between the two groups regarding the mode of actual delivery. 30women volunteers in the third trimester of pregnancy attending a public women's hospital with moderate levelsof FOC were included in the study. They were randomly distributed to 2 groups. The first group (n = 15)received six sessions of group art therapy. The second group (n = 15) received six sessions of psychoeducationfor FOC.

Results: By the end of the six weeks, Beck depression scale (BDS) scores, Beck Anxiety Scale (BAS) scores, andW-DEQ scores decreased significantly in the art therapy group in comparison to the psychoeducation group(p < 0.001). FOC was considerably decreased in the art therapy group in relation to the control group at the endof the treatment. Most of the women (n = 12) in the art therapy group had natural deliveries while those in thepsychoeducation group had C-sections (n = 10).

Conclusions: Our findings suggest that art therapy is an efficient method for reducing clinical FOC and levelsof anxiety and depressive symptoms in pregnant women in the final trimester. This arts therapy programmeenabled these shifts in behaviour by helping women face and express their fears through their artwork (drawing)and then gain control over their fears (mandala-making, puppet-making, taking photographs and collage-making) within a secure base and an on-going social support system provided by the group structure. Group arttherapy seems to be a cost-effective therapeutic approach for targeting a larger number of people in a limitedtime with a limited number of therapists.

Introduction

Even though most pregnant women might have some concerns re-garding the mode of delivery some women may experience a heigh-tened fear of childbirth (FOC), which may make pregnancy a disturbingand discomforting experience for these women. FOC may be acceptedas a natural reaction especially in nulliparous women. What is callednormal fear would not affect the everyday life of the woman and

decisions regarding the delivery method. There is no consensus on thedefinition of FOC. Some authors used the term “tocophobia” to reducethis confusion (Hofberg & Brockington, 2000). They defined tocophobiaas a condition where the woman had recurrent and intrusive thoughtsabout delivery and its possible complications such as harming the babyor not being able to give birth at all, and subsequent avoidance ofchildbirth. In a recent review “clinical FOC” is described as a disablingfear that intrudes with general functioning affecting the occupational,

https://doi.org/10.1016/j.aip.2018.11.007Received 28 November 2017; Received in revised form 31 July 2018; Accepted 24 November 2018

⁎ Corresponding author at: Altunizade Mahallesi, Haluk Türksoy Sk. No: 14, 34662, Üsküdar, Istanbul, Turkey.E-mail address: [email protected] (B.Ö. Ünsalver).

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Available online 26 November 20180197-4556/ © 2018 Elsevier Ltd. All rights reserved.

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domestic and social life of the woman, and in some cases meeting thedefinition of specific phobia (Nilsson et al., 2018). In this article, wechose to use “fear of childbirth (FOC)” instead of tocophobia because itis the most commonly used term for this condition in the availableliterature.

FOC may affect a woman’s general well-being and have negativeconsequences on the mode of delivery (Saisto & Halmesmaki, 2003).The woman may have a fear of giving birth even before getting preg-nant. However, the degree of the fear begins to increase by the twen-tieth week (Rouhe, Salmela-Aro, Halmesm, & Saisto, 2009). Prevalenceof FOC depends on cultural variables, the period of pregnancy, and thedifferences among methods of detecting FOC. However, it is estimatedto be observed by 15–20% on average (Fenwick et al., 2009).

The primary reasons for FOC are hearing others’ frightening de-livery stories (Melender, 2002), history of obstetric complicationsduring delivery (Størksen, Garthus-Niegel, Vangen, & Eberhard-Gran,2013), lack of knowledge regarding childbirth (Cleeton, 2001), fear oflabor pain (Aksoy, Aksoy, Dostbil, Çelik, & Ince, 2014), inadequatepsychological and physical support from the spouse throughout preg-nancy and during birth (Saisto, Salmela-Aro, Nurmi, Könönen, &Halmesmäki, 2001), lack of trust toward medical staff (Sjögren &Thomassen, 1997), lack of psychological support provided by the ob-stetrician, a history of anxiety disorders or depression (Saisto et al.,2001), sexual abuse (Boorman, Devilly, Gamble, Creedy, & Fenwick,2014), lower levels of education, young age pregnancy, unemployment,and low levels of income and social support (Boorman et al., 2014).

Untreated FOC in pregnancy may both prolong the delivery andincrease the subjective experience of labor pain which might result inthe registration of negative memories in the mother regarding birth(Goodman, Mackey, & Tavakoli, 2004). This disturbing delivery ex-perience may affect the mother’s future choice of birth method. Pro-longed delivery may also result in medical decisions such as epiduralanesthesia use, induction, assisted childbirth and emergency C-sections(Adams, Eberhard-Gran, & Eskild, 2012; Sydsjö et al., 2013). FOC alsoposes a risk for premature and postmature births and may cause post-traumatic stress disorder (Korukcu, Kukulu, & Firat, 2012) or post-partum depression, sexual dysfunction and lack of harmony in themother-baby relationship (Fisher, Hauck, & Fenwick, 2006).

Therefore, treatment of FOC is essential to prevent the aforemen-tioned negative consequences on the child and the mother. The objec-tive in treating FOC is to ensure a comfortable experience of pregnancy,facilitate the adaptation to motherhood and make sure that the motherfeels well in the postpartum period. The treatment options to manageFOC include breathing techniques, hydrotherapy, hypnosis, doula as-sistance, training for childbirth, psychoeducation (Rouhe et al., 2015;Toohill et al., 2014) psychotherapy that focuses on FOC and the four-step PLISSIT (Permission, Limited Information, Specific Suggestions,Intensive Therapy) model that has been adapted to FOC, which iscomposed of permission for individual sexual issues, limited informa-tion, specific suggestions, and intensive treatment when needed (Saisto& Halmesmaki, 2003).

The likelihood of having C-section birth is 5.2 times higher amongpregnant women with FOC (Sydsjö et al., 2013). Women requesting C-sections may change their minds and prefer vaginal birth after receivingpsychotherapy for FOC (Ryding, 1991; Sjögren & Thomassen, 1997). Ina study, it was found that a simple telephone psychoeducation inter-vention delivered by midwives to pregnant women with high levels ofFOC (W-DEQ A ≥ 66) was effective in decreasing levels of fear (Toohillet al., 2014) and the rates of C-sections (Fenwick et al., 2015).

Art therapy seems to be a promising method for managing variousantenatal and postnatal psychological problems such as depression,birth trauma or FOC (Hogan, Sheffield, & Woodward, 2017). Arttherapy with pregnant women has been shown to create positive effectssuch as relieving inner tension and decreasing levels of stress, anxietyand depression (Chang, Chen, & Huang, 2008; Demecs, Fenwick, &Gamble, 2011; Shin & Kim, 2011; Swan-Foster, 1989; Swan-Foster,

Foster, & Dorsey, 2003). A pregnant woman goes through prenatalbonding before birth and separation and postnatal bonding after birth.However, some women may experience difficulties while going throughthese stages which might cause psychophysiological dysfunctions in themother and the infant. Art therapy may help the woman to experienceprenatal bonding and expected separation and postnatal bondingthrough the therapy process and the artwork that is produced. Arttherapy encourages the pregnant woman to reconstruct her fears andconflicts into new representations that empower the woman as a mo-ther (Swan-Foster, 1989). Negative emotions are alleviated and re-es-tablished in a healthy bonding experience.

One of the first reports of art therapy in pregnancy was by NoraSwan-Foster on four pregnant women. The researcher utilized drawingself-portraits, fear, transformation of fear and closing mandala. Thesewomen gained increased self-awareness and decreased energy invest-ment in fears which resulted in higher self-esteem (Swan-Foster, 1989).Demecs et al. (2011), reported their observations regarding CreativeActivities in pregnancy program (CAP-Program). The program con-sisted of six two-hour sessions that used singing, dancing, storytellingand making an art project for the baby. Interviews with seven womenwho attended this program were reported. The women in the study didnot have clinical FOC. Art therapy worked as a basis for social supportfor them. The participants reported increased connection with self, withthe baby and with each other. They found balance in pregnancy andbalance in being ready for the upcoming birth and they took the bal-ance home (Demecs et al., 2011). Lee et al. (2014) presented a poster onan art therapy intervention study on 49 high-risk pregnant women whowere hospitalized. The number and structure of sessions were notspecified because this was a poster presentation. The method used wasdrawing. They found that stress management, emotional expression andverbal communication were improved with art therapy. In the study byWahlbeck, Kvist, and Landgren (2017), 21 women with severe FOC asmeasured by WDE-Q received five sessions of either individual or groupart therapy. 19 of these women were interviewed three months afterbirth. 15 had vaginal delivery. The interviews with the women revealedthat they benefited from art therapy in terms of decreased fear andincreased self-confidence, strength and hope. Their common difficultieswere feelings of carrying a heavy baggage and fear of hospitalizationprocess and physical damage. They acquired new insights and abilities.Art therapy helped them deposit their heavy baggage and facilitateattachment to the baby. The method that was used in the study waspainting. Although limited in number, these studies support the efficacyof art therapy for the management of psychological problems in preg-nancy.

The Turkish government has been trying to decrease the high ratesof C-sections in Turkey by law, threatening the doctors to impose fines(Letsch, 2012). However, according to an article by Betran et al. (2016)the rate of C-sections is still reported to be high in Turkey (47, 5%).Accordingly, we aimed to find a cost-effective and practical psy-chotherapeutic approach to manage FOC. In the light of all of theavailable data on art therapy, we hypothesized that art therapy wouldmeet our expectations. The primary purpose of this pilot study was toinvestigate the efficacy of group art therapy in comparison to a psy-choeducation group for the management of FOC. Turkey is a highlypopulated developing country. The number of available psychothera-pists is low compared to the population in need. So, we chose the grouptherapy approach as a cost-effective method suitable for middle andlow-income countries. Our target population was selected from amongpregnant women attending a general outpatient pregnancy follow-upclinic. We expected these women to be unfamiliar with psychologicalconcepts and practices of psychotherapy. So, we hypothesized that arttherapy would benefit these people without forcing them to speak theirminds but instead encouraging them to reconstruct their fears andconflicts into new representations that would empower them as a mo-thers (Swan-Foster, 1989). We tried to prepare a short-term but intensetreatment plan that targeted nearly all of the issues that might have

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resulted in or complicated FOC. We thought that psychoeducationwould provide a suitable comparison group for art therapy because it isan approach that is commonly used with pregnant women with FOC(Rouhe et al., 2015).

Methods

To understand the effectiveness of group art therapy, we designed aquantitative study. According to the PICO framework (Eden, Levit,Berg, & Morton, 2011) the studied population was pregnant womenwith subjective complaints of FOC attending an outpatient pregnancyfollow-up clinic. The effectiveness of the group art therapy interventionwas assessed in comparison to group psychoeducation for FOC. Theprimary outcomes of the study were determined as Wijma DeliveryExpectancy/Experience Questionnaire Version A (W-DEQ) scores below37, Beck Depression Inventory (BDI) scores below 14 and the BeckAnxiety Inventory (BAI) scores below 10 at the end of the 6th sessionfor the art therapy group. We expected to find significant differences inthe primary outcome measures between the two groups. The secondaryoutcome of the study was the difference between the two groups re-garding the mode of actual delivery.

Participants

The two groups were formed from consecutive pregnant womenwho had applied for a pregnancy training program that was run at aspecialized Women’s and Children’s Disease Training and ResearchHospital. We briefly explained the study to all pregnant women whoattended the hospital between January 25 and February 9, 2016. A fulldescription of the study was given to women who were interested, and15 women who were eligible for the study and who gave informedconsent were chosen for the art therapy group. A control group wasformed by 15 women who wanted to attend the hospital’s pregnancytraining program. Informed consent was also obtained from the controlgroup participants. The study took place between February 12, 2016,and March 18, 2016. Inclusion criteria were: (1) 28–32 weeks’ gesta-tion, (2) complaints of fear of giving birth, (3) not having participatedin any childbirth training before, and (4) age older than 20 years.Exclusion criteria for the study were: (1) risky pregnancy diagnosis, (2)hearing or visual impairment (3) any psychiatric or neurological diag-nosis, (4) already being involved in a psychotherapeutic process, and(5) using psychiatric medicine.

Group art therapy procedure

The study lasted six sessions, which was based on a previous studyof six-session group therapy on FOC (Rouhe et al., 2009). Psy-chotherapy for issues that are specific for and arise during pregnancyhas to be time-limited. Each session was 130 min long.

The structure of the art therapy sessions was as follows: preparationfor work (15 min), a warm-up stage that featured sharing the previousweek’s well-being and unshared products (15 min), a declaration of thenew session’s topic and activity (10 min), the application of artwork(40 min), sharing the final product (40 min), and closure (10 min). Thesession structure was adapted from Liebmann and ebrary Inc. (2004).

The scientific background for the different art therapy techniques that werechosen for each session

Listening to music and singingIn all six sessions, the group members listened to music and sang

together. Studies have shown that activities of listening to music andsinging activities contribute to the development of trust and commu-nication within a group. Music has positive effects on fear, anxiety, anddepression in pregnant women (Corbijn van Willenswaard et al., 2017).A study by Shin found that future mothers who listened to music for

25 min/day for 30 days in a group setting became more self-confidentby being supported by other group members, their maternal bondingimproved, and their anxiety was reduced (Shin & Kim, 2011). A two-week study conducted by Chang et al. (2008) with a treatment group of116 and a control group of 120 used music. As a result of the study, itwas observed that the levels of depression and anxiety in the futuremothers were reduced. Toker and Komurcu (2017) studied the effects ofTurkish classical music on women with pre-eclampsia. 70 women withpre-eclampsia were randomized into groups of either 30 min of rest orto 30 min of listening to music. In comparison to the control group, thewomen who listened to the “nihavend” and “buselik” modes of classicalTurkish music 5 days before and 2 days after labor had increased sa-tisfaction with nursing care and decreased blood pressure. ClassicalTurkish music had positive effects on fetal movements and fetal heartrate. In a study that was conducted in Taiwan, 296 pregnant womenwere randomized in an experiment group of listening to 30 min of pre-recorded music compact discs (CD) in addition to routine prenatal care(n = 145) and a control group that received routine prenatal care(n = 151) (Chang, Yu, Chen, & Chen, 2015). The tempo of the music inthe CDs were chosen to imitate the human heart rate of 60–80 beats/min. The trial lasted two weeks. Listening to music reduced pregnancy-related stress levels as measured by the Pregnancy Stress Rating Scale(PSRS). In another recent study, listening to pre-recorded music com-posed for the pregnancy over a period of twelve weeks reduced anxietyand depression symptoms significantly in comparison to a control groupof pregnant women who sat quietly and undisturbed (Nwebube, Glover,& Stewart, 2017).

Mask-makingMasks are a form of therapy and treatment, and they are the means

by which one freely expresses their identity within a group and revealstheir social roles. Group members are included in the group processwithout knowing each other, and each member may not have the sameease of expressing themselves or may hesitate to reflect themselves asthey are. Masks provide this freedom to individuals (Trepal-Wollenzier& Wester, 2002). Moreover, formation of group cohesion is based onsharing among group members, trust and honest expression. Mask-making was chosen for the members to express themselves honestlywithout making them feel naked, so that the group is allowed to pro-gress and develop.

DrawingEmotions and thoughts are reflected as concrete signs through

painting. Drawing is useful for enhancing self-reflection and promotingpersonal growth (Binson & Lev-Wiesel, 2017). Use of drawing has beenutilized in previous studies of art therapy with pregnant women (Swan-Foster, 1989; Swan-Foster et al., 2003; Demecs et al., 2011; Wahlbecket al., 2017). Fears surrounding birth may be expressed throughdrawing as shown by a study with 60 pregnant women with differentdegrees of prenatal problems by Foster, Foster, and Dorsey (2003).Cohen-Yatziv, Snir, Regev, Shofar, and Rechtman (2018) examined thedrawings of 11 primigravidae who had depressive symptoms. Ac-cording to the phenomenological analysis of the drawings, color usewas limited to a combination of blue and yellow, a rectangular pageformat instead of circular or oval page formats was preferred morecommonly, surroundings and details were lacking in the drawings, andthe represented objects were either separated or there was an absenceof holding. Some common themes that emerged were feelings of re-duction, inadequacy and simplification, and internal conflicts betweenpositive and negative feelings towards motherhood and separation. Thestudy suggested that drawings may provide valuable information fordiagnosing the psychological difficulties encountered by pregnantwomen that are not verbalized or that are not yet clinically dysfunc-tional. By using drawing, we aimed to help bring forward unspoken orunrealized fears of the women.

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Mandala-makingMandalas are a practical way to calm an individual's mind and de-

crease fear and anxiety (Curry, Kasser, & Galesburg, 2005; Drick, 2014).In a study, mandala drawings were found to be more useful in reducingstress than freehand drawing practices (Schrade, Tronsky, & Kaiser,2011). In another study with 67 adults, mandalas were an effective toolin transforming negative moods into positive moods (Babouchkina &Robbins, 2015). Chetu (2015) used mandala-making as a part of a four-session program designed for pregnant women to optimize prenatalattachment. Mandala-making was chosen to encourage the women tothink about their resources and emotional challenges and the effects ofthese on their relationship with their fetus in pregnancy. However, theeffects that are specific for mandala-making were not mentioned in thearticle. Mandala-making was chosen because there was a need for apractice that would help restructure and reintegrate the fears and otheremotions that would have been expressed in the previous session.

Puppet-makingMaking puppets and making them talk encourages people to so-

cialize, express themselves and resolve emotional conflicts. A puppet isa projective tool, encouraging the individual to uncover fears, concerns,and conflicts. Moreover, individuals embody their dreams and desiresthrough puppets, so, they have the opportunity to see what they wish tosee (Bender & Woltman, 1936). Throughout pregnancy, women dreamof what kind of a baby they will give birth to. Expectations arise inmany areas from the physical traits of the baby to the way it is raised.The first encounter is a surprise. For this reason, it is important to re-hearse this encounter and see in advance what future mothers expectfrom it and can offer to their babies. One of the most fundamental fearsof a woman about birth is the question of "Will my baby be fine?”. Wewanted to address women’s concerns regarding the baby by the way ofpuppet-making.

Taking photographsConverting something into a photograph is the equivalent to

wanting to own it. The individual has the opportunity to reflect theirfeelings while establishing a relationship between themselves and theoutside environment. The events or situations that are saved in pho-tographs depend on the desire of the person (Sontag, 1973). In a pho-tography study with adults, it was found that the participants werepositively affected in aspects such as trust, self-worth, and honesty(Glover-Graf & Miller, 2006). The purpose of photography being used asan art tool in therapeutic communication is to develop self-confidence,self-expression and general well-being (Weiser, 2001). As birth ap-proaches, women need courage and to trust themselves in the act ofgiving birth.

Collage-makingThe product that is created in a collage study depends on the ex-

periences that emerge until that moment and feelings at that moment.Decisions made during the study process ensure that autonomy is re-gained. Experiencing this autonomy and supporting personal commit-ment reveal the changes associated with the topic of the study. At theend of the study, individuals feel themselves balanced (Hopf, Elbing,Heußner, & Büssing, 2014). It is important that at the end of the studiesthat pregnant women depart from the group structure and return totheir individual structures and regain their own autonomy. These col-lages also reveal what pregnant women have gained throughout thesesix sessions before they leave the group.

Psychoeducation structure

The structure of psychoeducation sessions was as follows: the warm-up stage that featured sharing of the previous week’s well-being(20 min); a declaration of the new session's topic (10 min); sharing ofevery woman’s personal thoughts, feelings, and significant memoriesregarding the topic (30 min); psychoeducational information given bythe therapist regarding the topic (40 min); sharing of new thoughts orfeelings after psychoeducation (20 min); and closure (10 min).

The same therapist led both groups. She conducted both groups inthe same room but on different days of the week. She provided acomfortable environment for the pregnant women, prepared the ma-terials, and gave technical information when necessary. The structure ofthe sessions and the materials used are summarized in Table 1.

Measures

A sociodemographic questionnaire including age, gestational age,educational status, work status, and childbirth experience (primipara ormultipara) was completed by the women before the study.

Both the control group and the study group were assessed using theW-DEQ version A, BAI, and the BDI before starting the group therapyprocess (T1), after the third session (T2), and after the sixth session(T3).

We measured FOC using W-DEQ version A. The scale had 33 items,with scores from 0 to 5 for each. The higher the scores, the more fearfulthe pregnant women were about childbirth. Low fear was defined by aWDEQ-A score that was equal to or lower than 37, moderate fear wasdefined by a score between 38 and 65, and a high level of fear wasdefined by a score that was equal to or higher than 65 (Wijma, Wijma,& Zar, 1998) In the Turkish validity and credibility study of the scale,Cronbach’s alpha was determined as 0.92 (Korukcu et al., 2012).

The BAI is a 0–3 Likert scale of 21 questions developed by Beck todetermine the severity of anxiety symptoms (Beck, Epstein, Brown, &

Table 1Structure of psychotherapy sessions.

Sessions Content Art therapy group Control group

1st session Meeting of the group members. Forming group rules. Introduction to the group processand setting goals.

Mask makingListening to music and singing

Pen and paper

2nd session Describing the features of fear of giving birth. Explaining the reasons underlying fear ofgiving birth. Exploring personal causes for each woman for their fear of giving birth.

DrawingListening to music and singing

Book reading (Birthing from within byPam England)

3rd session Management of fear by becoming aware of different solutions and choosing one thatsuits best for the individual. Practicing mental imagery guided relaxation breathing.

Mandala makingListening to music and singing

Book reading (Hypnobirthing byMarie F Mongan)

4th session Bonding with the baby exercise. Defining the attachmenttheory and features of secure and non-secure attachment. Explaining the effects of skinto skin touch on the interaction between the mother and the baby.

Puppet making Listening tomusic and singing

Pen, pencil, powerpoint presentation

5th session Exploring the perceptions of each pregnant women regarding giving birth to a child.Talking about personal thoughts on concepts of success and failure. Encouraging self-compassion, self-confidence, and courage.

Taking photographs Listening tomusic and singing

Pen, paper

6th session Clarifying the expectations of the woman from their spouses, family, and medical staffduring their delivery. Going through personal gains attained during therapy.Monitoring general mood of the pregnant woman. Closing the group work.

Making collage paintingsListening to music and singing

Pen, paper

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Steer, 1988). The Turkish validity and credibility study of the scaleshowed good psychometric properties (Ulusoy, Sahin, & Erkmen,1998). The total score of the scale varies between 0 and 63. A score of0–9 points is classified as “normal or no anxiety,” 10–18 as “mild tomoderate anxiety,” 19–29 as “moderate to severe anxiety,” and 30–63as “severe anxiety.”

The BDI is a self-assessment scale of 21 questions developed by Beckto detect depression risk and the level of depressive symptoms (Beck,Ward, Mendelson, Mock, & Erbaugh, 1961). The total score of the scalevaries between 0 and 63. A score of 0–13 points is classified as “nodepression,” 14–24 points as “moderate depression,” and 25 and aboveas “severe depression.” The Turkish validity and credibility study of theBDI showed good psychometric properties (Hisli, 1989).

Statistical analysis

This study used and experimental pre-test (T1), mid-test (T2), andpost-test (T3) control group design. This study used frequencies (N),percentages (%), means ( ± standard deviation), medians (because thedata was skewed for the quantitative scale scores), and 25% and 75%percentiles as descriptive statistics. All of the measurements werecomputed at T1, T2, and T3. The analysis of the categorical data wasconducted using the Chi-Squared test (Table 3). The data did notcomply with a normal distribution, so, Mann-Whitney U test was usedfor the analysis of the independent variables (art therapy and psy-choeducation) and Friedman two-way ANOVA test was used for theanalysis of the dependent variables (W-DEQ, BAI, BDI scores) (Tables4–6). The statistical significance level was accepted as p < 0.05.

Ethical considerations

Permission to perform this art group therapy and psychoeducationstudy was granted by the Training and Research Hospital that this studytook place, and the study was conducted after approval from the ethicalcommittee of a Turkish University. The ethical standards of the HelsinkiDeclaration were followed. The costs of the research were covered bythe researchers. All the pregnant women gave informed consent beforethe study.

Results

Quantitative results

The women in the art therapy group were older (mean = 28,SD = 4.9) than those in the control group (mean = 26.3, SD = 4.8).Five women in the art therapy group were housewives, while eight inthe control group were housewives. There were no significant differ-ences between the groups regarding other demographic characteristicsand their histories of pregnancy (Tables 2 and 3).

At T1, the median BAI scores were 24 and 22 for the art therapy andcontrol groups, respectively, suggesting moderately increased anxiety.The median BDI scores at T1 were 23 for both the art therapy andcontrol groups, indicating moderately depressive symptoms. At T1, themedian W-DEQ scores were 51 and 56 for the art therapy and controlgroups, respectively, suggesting moderate FOC. There were no

statistically significant differences regarding the W-DEQ, BAI and BDIscores between the art therapy and control groups at T1 (p = 0.345,p = 0.461 and p = 0.653, respectively) (Tables 4–6). At T2, the BDIscores were found to be significantly lower in the art therapy group(p < 0.001) (Table 6). At T3, the median BAI and BDI scores for the arttherapy group (8 and 7, respectively) were both below the cut-offscores. However, the median BAI and BDI scores for the control group(23 and 21, respectively) were both above the inventories’ cut-off scoresat T3, indicating persistent symptoms of anxiety and depression. Themedian W-DEQ score for the art therapy group at T3 was 28, which isaccepted as a low level of fear. The median W-DEQ scores remainednearly the same at T1, T2 and T3 (56, 55 and 55, respectively) in thecontrol group, suggesting a sustained moderate level of FOC. At T3, theBAI, BDI and W-DEQ scores were found to be statistically significantlylower in the art therapy group (p < 0.001) (Tables 4–6) (Figs. 1–3).

More women in the art therapy group (n = 12) than in the controlgroup (n = 5) had vaginal delivery (Table 7). The reasons for C-sectionin the art therapy group were: baby weighing heavier than 4 kg, fetaldistress and prolonged labor. Ten women in the psychoeducation grouphad C-sections. 7 had elective C-sections because of fear of deliveryroom, fear of episiotomy, traumatic memory of previous natural de-livery and fear of harming the baby because the baby was the result ofin vitro fertilization. The remaining 3 C-sections were because ofmedical conditions (overweight baby, occipital presentation, non-pro-gressive labor).

Qualitative findings for the art therapy group

Common concerns of women when they started therapyWill my baby be healthy? What if delivery harms my baby?Will I be able to give birth? What if I cannot have a vaginal delivery?

What if I will shout too much?Will I be able to take care of my baby? Will I be a good mother?What will the delivery process be like? What if I will be alone during

delivery?They had imagined the pain associated with delivery as unbearable.

Some women thought they would get so exhausted in labor this wouldprevent the baby from being born. Some feared that the birth wouldharm the baby.

Common interpretations of pregnant women regarding group art therapyNearly all women said they were at first reluctant to start therapy

but admitted that they felt relieved after hearing similar stories fromother women which made them feel supported. Some of them said theyhad doubted the efficacy of art in decreasing their fears. However, asthe study progressed, they saw how their fears and conflicts were re-flected in their artworks. One woman said, “I saw how all emotions

Table 2Demographic features of the participants.

Art therapy group Control groupMean SD Mean SD p

Age 28.0 4.9 26.3 4.8 0.354Number of pregnancy 1.5 0.7 1.3 0.6 0.200Gestation week 31.2 2.6 31.0 3.0 0.200

*t–test.

Table 3Demographic features of the participants (Descriptive statistics).

Art therapygroup

Controlgroup

N % N %

Education High-school 4 26.7 4 26.7University 11 73.3 11 73.3

Work status House-wife 5 33.3 8 53.3Working 10 66.7 7 46.7

Place of residency City 15 100 15 100Type of family extended 3 20 2 13.3

nuclear 12 80 13 86.7Planned pregnancy? Yes 13 86.7 14 93.3

No 2 13.3 1 6.7History of miscarriage,

abortion or ectopicpregnancy

Yes 2 13.3 1 6.7

No 13 86.7 14 93.3

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could come to the surface with colors, pictures and music.”

The effects of some techniques on womenThose who were concerned about the safety and health of their baby

regarding the negative effects of delivery on the baby said they bene-fited the most from the puppet-making. They said that “meeting thebaby through the puppet was like a rehearsal for the real baby.” Mostwomen expressed intense emotions during the puppet-making session.

Those who were concerned about having disruptions during thenatural course of delivery stated that the mandala technique calmedthem. One participant said “Imagining the vagina as a mandala wasexciting. Every circle that I drew was like the opening of my cervix foreasing the labor, and I got more relaxed with every circle I drew.”

The artwork from the art therapy sessions may be seen in Images1–4 .

Table 4Comparison of WDEQ Scores at T1, T2 and T3 in the art therapy and control group.

Art therapy group Control group

Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75 p

T1 51.00 36.00 56.00 56.00 42.00 58.00 0.345T2 41.00 31.00 46.00 55.00 41.00 58.00 0.004T3 28.00 21.00 32.00 55.00 42.00 56.00 < 0.001

*Mann Whitney U.

Table 5Comparison of the BAI scores at T1, T2 and T3 in the art therapy and control group.

Art Therapy group Control group

Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75 p

T1 24.00 23.00 25.00 22.00 21.00 44.00 0.461T2 20.00 19.00 21.00 23.00 22.00 45.00 0.016T3 8.00 4.00 12.00 23.00 22.00 45.00 < 0.001

*Mann Whitney U.

Table 6Comparison of the BDI at T1, T2 and T3 in the art therapy and control group.

Art therapy group Control group

Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75 p

T1 23.00 21.00 24.00 23.00 20.00 26.00 0.653T2 16.00 14.00 17.00 23.00 21.00 25.00 < 0.001T3 7.00 6.00 9.00 21.00 19.00 24.00 < 0.001

*Mann Whitney U.

Fig. 1. Change in BAI Scores.Fig. 2. Change in BDI Scores.

Fig. 3. Change in W-DEQ Scores.

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Discussion

This study examined the efficacy of six sessions of group art therapyin comparison to a psychoeducation group for managing FOC. Theprimary outcome of the study was a significant decrease in WDEQ, BAIand BDI scores in the art therapy group in comparison to the controlgroup at the end of the treatment. The secondary outcome was in-creased rates of natural deliveries in the art therapy group (n = 12) incomparison to the psychoeducation group (n = 5). It may be stated thatsignificant decrease in WDEQ predicted increased rates of vaginal birth.This is consistent with previous studies where women changed theirminds about their method of birth after receiving psychotherapy forFOC (Fenwick et al., 2015; Ryding, 1991; Sjögren & Thomassen, 1997).The increased vaginal birth rates may be interpreted as evidence of theefficacy of the group art therapy for managing FOC in our study.

Our findings of decreased anxiety and increased well-being werecongruent with those of previous studies on art therapy for pregnantwomen (Swan-Foster, 1989; Swan-Foster et al., 2003; Chang et al.,2008; Demecs et al., 2011; Shin & Kim, 2011; Chetu, 2015; Wahlbecket al., 2017). Most reported art therapy studies used the methods ofmusic and drawing. In our study, in addition to music, we used other

Table 7Types of delivery in the art therapy and control groups.

Normal delivery (n) Caeserian section (n)

Art therapy 12 3Control group 5 10

Image 1. Lower left image is collage work from the 6th week. Other images are from the mandala session drawings on the 3rd week.

Image 2. Drawing from the 2nd week.

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techniques such as making masks, collages, puppets, taking photo-graphs and making mandalas to involve the pregnant women in variousperspectives to be able to address different issues related to FOC.Therefore, our report seems to be the first study of group art therapyusing different artistic techniques for managing FOC.

The interpersonal neurobiology perspective defines psycho-pathology in terms of suboptimal integration and coordination in theneural networks of the brain (Cozolino, 2002). Accordingly, psy-chotherapy is a way of creating and/or restoring neural network in-tegration and coordination. Art therapy stimulates both hemispheres ofthe brain through sensory, perceptual, emotional and cognitive pro-cessing and integration is possible with facilitated attention, increased

communication and logical understanding (Hass-Cohen & Findlay,2015 p.21, p 331). In the light of this knowledge, we propose that thepositive primary and secondary outcomes in just six sessions of arttherapy were the results of multimodal stimulation of the body and thebrain, and we facilitated neural integration by our use of different ar-tistic techniques in each session.

The engaging attitude of the art therapist must have also helped tobuild a therapeutic alliance with the women. One important factorcontributing to change in psychotherapy is the therapeutic alliancebetween the therapist and the patient. The warmth, empathy, en-couragement, and acceptance by the therapist form the basis of thistherapeutic alliance (Hubble, Duncan, & Miller, 1999). The art therapistin this study fits into this description.

Although there are studies of art therapy with pregnant women, wecould not find another well-structured study that specifically targetedFOC except the study by Wahlbeck et al. (2017). Unlike the case in ourstudy, they recruited women with severe FOC for five sessions of arttherapy. The only technique they used was drawing. They also struc-tured every session on a topic relevant to FOC. The vaginal birth rate(15 out of 19 women) in their study was similar to ours. So, it may bestated that even though they had one fewer session than our study anddid not use as many art therapy techniques as ours, their outcomes weresimilar. In a future study, our art therapy structure with various tech-niques may be compared to a control group where drawing is the onlytechnique used.

Music was commonly used in previous studies and chosen to relaxwomen during the sessions and encourage them to express themselvesmore freely in a safe and relaxed environment. It was observed thatstarting the sessions with music helped the women to get involved intheir artwork easily. However, we cannot specify if music was thecomforting element as we had music in all six sessions. Therefore, tounderstand the effects of music another study may form an art therapygroup for FOC without music as a comparison group.

Image 3. Drawing from the second week.

Image 4. Puppet making session on the 4th week.

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We did not find another study where puppet-making was used forFOC. The puppet-making session was highly appreciated by the women.Most of the women had fears concerning the health of their baby andfears of harming the baby during delivery. The puppets that were madeby the women might have had a resemblance to the baby that was in away made by the pregnant women via nurturing and carrying the babyin the womb starting from conception till delivery. So, in a way, theymet their possible “product,” which made them feel more competent asthe future mother of the real baby. In addition to this, it might also havebeen easier to project fears and fantasies into a puppet baby than anabstract mental representation, which must have decreased the anxietyof uncertainty. Puppets may be similar to the transitional objects(Trimingham, 2010) defined by Winnicott (1953), where puppets helpwomen form a preliminary mental representation of the baby. Wesuggest puppet-making could be a useful practice in art therapy sessionswhile working with pregnant women.

The study by Demecs et al. (2011) used the methods of dancing andweaving (as a project for the baby). We did not include dancing becauseTurkish women are usually ashamed to dance in front of strangers or inunfamiliar places. Knitting or crocheting things for the baby in preg-nancy are ordinary activities performed by Turkish women and theirrelatives. So we did not find it useful to include in our therapy.

We chose group therapy to be able to reach more women. Accordingto Spiegel (1994), group therapy has three advantages. Firstly, thegroup environment provides its members with social support. Accord-ingly, in a meta-analysis of 59 studies on postnatal depression, it wasconcluded that support groups and having someone to talk to were themost effective treatment approaches (Dennis & Chung-Lee, 2006).Secondly, the members have an environment outside of their familieswhere they can objectively share their concerns. Finally, the groupsystem is low cost, and time is used more efficiently. Art therapy,contributing to group cohesion, enables a person to feel less anxiety inthe protected structure of a group (Demecs et al., 2011; Shin & Kim,2011). In our communications with the art therapy group, nearly allwomen said they were at first reluctant to start therapy but admittedthat they felt relieved after hearing similar stories from other womenwhich made them feel supported. The group members became a part ofeach other’s support system. The pregnant women in the art therapygroup exchanged their phone numbers and formed a group in an in-stant-messaging application where they shared their thoughts andfeelings after the therapy sessions were over. They asked for help fromeach other on issues such as breastfeeding or other mutual problems oftaking care of their babies through this messaging application. This wasnot something the therapist suggested. It was their decision. This mayindicate that these women who were strangers before the therapies feltthe warmth and protective environment of the group and wanted toextend this relationship to their everyday lives. So, it may be stated thatthe group therapy approach reached its goal of being a safe and pro-tective social support system.

There was no improvement in the psychoeducation group whichcontradicts the results reported in the literature (Fenwick et al., 2015;Rouhe et al., 2009, 2015; Toohill et al., 2014). The psychoeducationgroups in Rouhe et al.’s (2009) study consisted of six pregnant womenat most. Our control group included 15 women. This relatively highnumber in the control group might have decreased the efficacy of thetreatment. Group psychoeducation might be more efficient with fewergroup members. Psychoeducation might have been experienced like aformal education group that did not focus on the personal concerns ofeach woman, and the participants might have felt like students. InTurkey, students are not interactive participants of classes, but they aregenerally passive and obedient takers. On the contrary, art therapyrequired the women to be interactive. The art therapist engaged witheach pregnant woman when she instructed, listened and supported theproduction of artwork. This might have increased the well-being of thewomen. We suggest that art therapy could be helpful for cultures whereverbalizing feelings and thoughts is difficult.

Hypnobirthing is a popular technique for supporting natural de-livery (Mongan, 2005), but it is rarely used in Turkey due to the lack ofeducated staff trained on this technique. Hypnobirthing does not focuson the personal concerns of the individual pregnant women but onrelaxation exercises and education of women regarding the process ofdelivery in similarity to the psychoeducation group. Therefore, arttherapy may seem superior concerning its focus on the psyche of thewoman in various aspects.

In line with the available literature, as the level of FOC measured byW-DEQ increased, so did the symptoms of anxiety and depression inboth groups (Erkaya, Karabulutlu, & Çalık, 2017; Størksen et al., 2013).We used BDI and BAI to check for depressive and anxiety symptoms,and the BDI and BAI scores were above their cut-off points beforestarting the treatment in both groups. These women did not have aprior psychiatric disorder. Therefore, we attributed the increased BDIand BAI scores to FOC. The BDI score measurements began to showsignificant decreases starting from T2, and the BAI score measurementswere significantly lower at T3 in the art therapy group. So, as the fear ofgiving birth decreased, the women’s overall psychophysiological func-tioning improved, and the vaginal birth rates among the women in-creased consequently. These findings may suggest two things. Firstly, itmay be stated that clinical FOC is a separate condition from anxiety ordepressive disorders. Therefore, during treatment, specific issues re-lated to FOC need to be addressed. Secondly, the decrease in WDEQscores may predict both the efficacy of treatment and the subsequentmode of delivery. So, if the WDEQ scores do not decrease considerablywhen the treatment is finished, further therapeutic work with the ad-dition of other techniques may need to be planned, which complieswith the PLISSIT model (Saisto & Halmesmaki, 2003).

Previous research included women with severe FOC (W-DEQ > 66)(Fenwick et al., 2015; Rouhe et al., 2015; Toohill et al., 2014; Wahlbecket al., 2017). However, our study and control groups included womenwith moderate levels of FOC. Therefore, our results may not be com-parable to those in previous research. Moderate levels of FOC may alsobe disturbing for the women as reflected in the increased levels of an-xiety and depressive symptoms in our groups. The importance ofmoderate levels of FOC on delivery methods has not been studied ex-clusively. Moderate FOC may go unnoticed and undealt with. However,the ten women in the psychoeducation group with moderate FOC hadC-section deliveries, which might suggest a possible impact of moderateFOC on the delivery method. Our study highlights the need for ques-tioning FOC in every pregnant woman and targeting not only those withsevere FOC but also those with moderate FOC as well.

This study had some limitations. The research was based on one arttherapy and one control group with a sample from only one hospital.There was only one therapist conducting the therapy sessions. Thismight have caused a positive bias toward art therapy because arttherapy requires the therapist to interact with the participants in an in-depth manner. This could have created a better therapeutic alliancebetween the therapist and the participants, and the therapist mighthave subconsciously favored those in the art therapy group over thepsychoeducation group. The art therapy and control groups were lim-ited to 15 women each. Although our sample was small, it might be agood representation of Turkish pregnant women because the Hospitalwhere the study took place is a venerable and well-known hospitalamong Turkish people that specializes in obstetrics and gynecology carefor women from low- and middle-income backgrounds in a central areaof Istanbul. The research included only pregnant women in their finaltrimester. Fear of giving birth is not confined to the final trimester, andsome women may avoid getting pregnant due to FOC. Therefore, theefficacy of art therapy needs to be studied in different trimesters andbefore pregnancy as well. The prevalence of domestic violence inTurkey is high (57.2%) (Özcan, Günaydın, & Çitli, 2016). Domesticviolence in pregnancy was reported to be 39.8% in a Central-Anatoliancity of Turkey (Alan, Koc, Taskin, Eroglu, & Terzioglu, 2016). Domesticviolence in pregnancy may increase or cause FOC (Hossieni, Toohill,

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Akaberi, & HashemiAsl, 2017). We asked the participants about theoccurrence of any new adverse events in their lives at T2 and T3 toexclude any factors that may interfere with their psychological well-being. No adverse events were reported. However, domestic violencewas not questioned directly. Women may be ashamed or afraid oftalking about their domestic violence experience, or they might havenormalized it. Occurrence of domestic violence needs to be addressed inpregnant women with FOC.

Conclusion and recommendations

To conclude, our findings suggest that art therapy is an efficientmethod for reducing FOC and levels of anxiety and depressive symp-toms in pregnant women in their final trimester. This art therapy pro-gram enabled these shifts in behavior by helping the women face andexpress their fears through their artwork (drawing) and then gaincontrol over their fears (mandala-making, puppet-making, taking pho-tographs and collage-making) within a secure base and an on-goingsocial support system provided by the group structure. Art therapy canbe used to change perceptions regarding delivery. Art therapy may beemployed as a method of relaxation, relief and encouragement throughself-expression for pregnant women in preparation for childbirth.Personalized treatment that focuses on a pregnant woman’s individualneeds might be more productive. However, group therapy may be morecost-effective for larger groups, especially in developing countries or forwomen from low-income backgrounds. We suggest that pregnantwomen receive psychological support in the process of preparation fordelivery. A birth psychologist specializes in issues regarding birthpsychology, birth physiology and interpersonal relationships of preg-nant women and offers psychotherapeutic approaches to problems thatarise in pregnancy (Karabekir, 2016). The effectiveness of the birthpsychologist may increase in the course of overcoming FOC, whichimpedes the rates of vaginal births.

Funding

This research did not receive any specific grant from fundingagencies in the public, commercial, or not-for-profit sectors.

Declarations

Part of this work has been presented as a poster presentation at the25th European Congress of Psychiatry and it’s abstract has been pub-lished in European Psychiatry 2017, vol: 41, p909. https://doi.org/10.1016/j.eurpsy.2017.01.1868.

Acknowledgments

The presented paper includes some of the findings from the Master’sThesis of the second author.

The second author designed the structure of art therapy sessions andalso conducted the group therapies.

The first author planned the methods of the study and interpretedthe findings of the study. The first author wrote this manuscript.

The nurses in the hospital helped with the referral of the pregnantwomen, and they also provided a comfortable space for group thera-pies.

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