Understanding and responding to women’s beliefs and attitudes during the childbearing period is an important focus of international maternity health policy. The terms ‘woman centred care’ and ‘informed choice’ reflect that in addition to the physiological aspects of pregnancy and birth, there are psychological, psychosexual, and psychosocial aspects unique to the individual life experiences of pregnant women. These must be considered in order to optimise a woman’s birth outcomes and experience [1
]. The psychosocial wellbeing of women is now viewed as equally important as her physical wellbeing [2
In a ‘woman centred’ approach the clinician moves beyond medico/protocol/risk centric care and seeks to better understand the individual woman through ascertaining her attitudes to pregnancy and birth and her particular life situation [3
]. Attitudes have been conceptualized using a three-component model: affective, cognitive and behavioural [4
]. The affective component consists of positive or negative feelings toward the attitude object; the cognitive part refers to thoughts or beliefs; and the behavioural element represents the actions or intentions to act upon the object. Social psychologists differentiate a belief from an attitude by suggesting that a belief is the probability dimension of a concept – ‘is its existence probable or improbable?’
] An attitude on the other hand, is the ‘evaluative’ dimension of a concept. ‘Is it good or is it bad?
]. A change in attitude toward a given concept can result from a change in belief about that concept [5
The ‘Harsanyi Doctrine’ [6
] asserts that differences in individuals' beliefs can be attributed entirely to differences in information [7
]. Applying this doctrine to maternity care, it is interesting to consider where, what, how and by whom, information is shared between women and their care givers and what impact this may have on their beliefs and attitudes. A recent study of 1,318 low-risk Canadian women conducted by the University of British Columbia and the Child & Family Research Institute [8
] illustrates this point. Focusing on attitudes to birth technology, the Canadian study reported that women attending obstetricians were more favourable to the use of birth technology and were less appreciative of women's roles in their own birth. In contrast, women attending midwives reported less favourable views toward the use of technology and were more supportive of the importance of women's roles. Family practice patients' opinions fell between the other two groups. These women could be a self selecting population who choose a particular care giver according to their pre-existing attitudes, or alternatively the attitudes of the women could be influenced by the information they receive from their caregiver.
The determinants of a woman’s attitudes and beliefs are inherently linked to cultural and health system specific influences [10
]. In risk-averse biomedical systems of care the woman’s attitudes and beliefs about birth may determine the level of intervention that she actively chooses or passively receives. With the aim of examining changes over time (1987-2000) in women’s expectations and experiences of intrapartum care, the Greater Expectations Study [11
] surveyed approximately 1400 pregnant women across several health services in the United Kingdom (UK). It demonstrated that women’s attitudes and expectations had shifted over the thirteen year period from when the original study [12
] had been undertaken. The findings showed a relationship between childbirth outcomes and women’s antenatal attitudes. The issue of greatest concern to the authors was the increase in women’s antenatal anxiety about pain and their reduced faith in their ability to cope with labour [11
]. Over the same time period there was an increased use of obstetric interventions, especially induction, epidurals and caesarean sections. Mean scores on a scale designed to measure a willingness to accept interventions (‘attitude to intervention’) were significantly higher in 2000 than in 1987. Women who went on to have unplanned caesarean sections or assisted deliveries had significantly higher ‘attitude to intervention’ scores antenatally than women who went on to have unassisted vaginal deliveries. The study suggested that an explanation for this was an increased use of epidurals by women who were positive about interventions [13
]. In 2001 an audit report was tabled in the UK as an investigation of the patterns of, and the reasons for, caesarean [14
]. This report included women’s responses to a range of attitudes and beliefs about childbirth. The findings indicated that women who preferred caesarean as the mode of birth held attitudes reflecting a belief that birth was not a natural process and that they were concerned about control and pain and safety.
In clinical practice ‘woman centred care’ and ‘informed choice’ have manifested in such practices as the distribution of evidenced based information brochures, client-held medical records, birth plans and formal screening for psychosocial pathology- in particular perinatal depression and domestic violence [15
]. Despite the rhetoric, women’s individual circumstances, attitudes, beliefs and choices are not necessarily at the centre of the decisions made in regard to her care. The term ‘woman centred care’ is not a commonly used term in Swedish maternity policy. Women’s personal autonomy is politically important, but the concept of ‘informed choice’ is limited by the State– for example under the universal state funded health system women have no freedom to choose their model of maternity care nor mode of birth [20
]. In Australia, choice is often limited by the region where a woman accesses care [21
In addition to the diagnosis of perinatal depression, researchers and clinicians are increasingly recognising the importance of pregnancy-specific anxiety, with fear of childbirth being a sub construct of this anxiety [22
]. A clinically significant fear of childbirth is estimated to affect 20 to 25% of pregnant women and the prevalence of severe fear that impacts on daily life is thought to be between 6 and 10% [23
]. Most of the literature regarding childbirth fear has been focused on Scandinavian populations, however childbirth fear crosses cultural boundaries as studies from Australia [28
], the UK [30
], Switzerland [31
], United States [32
] and Canada [23
] attest. In an effort to understand a woman’s attitude or belief about birth it is important therefore to add the impact of fear to gain a fuller picture.
In 1985, Raphael-Leff published profiles of pregnant women [33
] where she described mothers in four categories: ‘Facilitator’, ‘Regulator’, ‘Reciprocator’, and ‘Conflicted’ (Table ). Her model, which is based on her extensive clinical experience, mother-child observations and survey data, postulates that there is a variety of approaches to pregnancy and early motherhood within and between societies. She describes these as ‘orientations’ and, while other studies have linked particular personality traits to phenomena such as a request for caesarean for non medical reasons [34
], Raphael-Leff states clearly that her model is not about personality traits. Different pregnancies and differing circumstances mean that a woman’s orientation may change with each gestation [33
A recent prospective study from Belgium [36
], attempted to predict a woman’s childbirth experience using antenatal expectations of birth and the Raphael-Leff model of orientations. While the antenatal expectations of the women clearly predicted their postpartum recollection of intrapartum experiences, the study did not support the independent contribution to birth experience of the Raphael- Leff orientations after obstetric complications were taken into account. There was a suggestion however, that maternal orientations made some contribution to the childbirth experience.
To assist clinicians in their efforts to sensitively and effectively place women at the centre of maternity care, more knowledge is required about how women think about birth and the extent to which they are fearful. Further empirical research therefore is needed to better understand attitudinal profiles in pregnant women and the association this has with their pregnancy outcome and experience.
In this study we aimed to identify profiles of pregnant women based on their attitudes to and beliefs about birth and their levels of childbirth related fear. We aimed to compare pregnancy characteristics, outcomes and experiences of birth between these profiles. Our hypothesis was that women with an elevated fear of birth would emerge as a distinct profile that had poorer pregnancy and birth outcomes than other women.