Methodology
This particular study will employ a descriptive survey that will help in describing the increasing cases of caesarean section (elective and emergency) and its relationship with fear of childbirth. Descriptive surveys often describe the way an issue is on the ground without manipulating any particular variables. The design is thus chosen to establish the various factors that bring about childbirth fear which in return impacts on the rate of caesarean section among primiparous and multiparous women at Rosie Hospital, under the management of Cambridge University Hospitals.
Rosie Hospital is located along Addenbrooke’s Hospital’s Hills Road on Robinson Way, Cambridge CB2 0SW, UK. The facility mainly provides maternity services and is managed by Cambridge University Hospitals. It has about 120 beds and operates on a 24-hour routine. The facility also offers neonatal and gynecology services. It is thus suitable for this particular study.
The targeted participants include both multiparous and primiparous women scheduled to give birth at the Rosie Hospital. Being one of the main maternity facilities out of all the Cambridge University Hospitals, Rosie Hospital receives many pregnant women who come for both antenatal and postnatal care.
This study will involve at most 100 participants recruited selectively. Of the 100 selected, 50 must be multiparous women while the other 50 must be primiparous. This will help in minimizing a likely bias on the information obtained from both groups of women.
The Rosie Hospital will be purposively selected because it contains the population of interest. This is especially considering that the facility has a large catchment area. The respondents will be recruited based on their willingness to participate in this particular study. Selective sampling will be used in choosing participants to ensure that the number of multiparous women under study is equal to that of primiparous respondents. The women will be recruited during their routine foetal ultra-sound examination visit during week 17 of the pregnancy.
The rate of Caesarean Section (elective and emergency) among primiparous and multiparous women
Fear of Childbirth
Social support factors
Depression
Anxiety
Medical risk factors
Sexual Abuse
The study will include pregnant women willing to fill in the provided questionnaires after visiting Rosie Hospital for their 17nth Week ultrasound exam routine visit.
Those who indicate that they are not likely to remain within the Hospital’s catchment till their delivery will not be included.
A pilot study will be done to determine the validity and reliability of the instruments. Rosie Hospital will still be used for the pilot study. The researcher will issue 10 questionnaires to 10 of the legible participants based on the inclusion criteria. Even so, those who participate in the pilot study will not be allowed to participate in the final study despite having similar characteristics with the ideal participants for the study. The main purpose of the pilot study will mainly to test the validity and/or reliability of the instruments. In particular, it will help in checking whether the questionnaires cover enough of the data required. It will also help in clarifying any identified ambiguities in the structuring of the questions so as to find improvements. This as well will help reveal flaws in the questions and in address inadequacies in the coding system that informs data analysis. The pilot data will then be analysed and the results will be used to modify questionnaires before the actual study.
Sample
This study will collect data using questionnaires written in English. Questionnaires will contain both open and closed ended questions. About 100 questionnaires will be distributed to the main respondents in the study area. The questionnaires will be self-administered where possible. The questionnaires will have sets of questions that will be filled while the pregnancy is at 17nth Week (first set of questions), 32nd week (Second set), and 2 weeks post-partum (final set). The researcher with the assistance of the research assistants will ensure that the participants fill in the questionnaires, responding to the appropriate sets of questions. Every woman asked to take part in the study will be provided with written information that will explain the purpose of this particular study. They will, more importantly, be informed that participating will be voluntary but be encouraged to commit themselves to complete all the sets of questions at the 17nth Week, 32nd week, and 2 weeks post-partum. Informed consent will be obtained from each of the legible participants. This study will be approved by the ethics committee of the Anglia Ruskin University, UK.
3.8.1 Measures
- Fear of childbirth
This measure will be determined using the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) in the second set of questions (32nd Week of pregnancy). This tool (i.e. the W-DEQ) is mainly a self-assessment rating scale with 33 items. Every response is rated based on a Likert scale of six points which range from 0 to 5 (Storksen, Garthus-Niegel & Adams et al., 2015). The sum total of the scores can range from point 0 to 165. Higher scores in this regard will reflect a greater fear of childbirth degree. The researcher will consider the fear of childbirth to be ≥85 based on the W-DEQ total score. The cut-off is the most commonly used in distinguishing between those women that have the fear of childbirth and those who do not.
- Social Support
This measure will be determined two weeks after the mother delivers using the Oslo Social Support Scale. This scale has been severally utilized in research to determine an individual’s distress related to social support factors in place during the gestational period (Fuglenes, Aas, & et al., 2013). This means that it will be incorporated in the last set of questions in the questionnaires (2 weeks post-partum). The total score on this scale will be arrived at by adding the different item scores. More particularly, the summed scores will range between 3 and 14 where 3 to 8=poor, 9 to 11=moderate, and 12 to 14=strong support.
- Sexual Abuse
Findings
This measure will be determined using an Abuse Assessment Screen in the form of questions. These questions will be incorporated in the final set of questions within each questionnaire. This will be done 2 weeks after delivery. Among the questions that will feature in the Abuse Assessment Screen will include; “Have you ever been coerced into sexual activity?” This tool according to Handelzalts, Fisher, & Lurie et al (2012) can help in determining the influence of forced sexual activity on fear of childbirth and its consequential impact on the rate of caesarean Section.
- Depression
Depression as a measure will be determined based on the rating of its symptoms by the patient during the previous week. The measure will be done in the second set of questions in the questions (32nd Week of Pregnancy). In particular, the Edinburgh Postnatal Depression Scale (EPDS) can be used in to determine depression in the women (Rouhe, Salmela-Aro, & Gissler et al., 2011). The scale consists of 10 items that can be used in self-rating to determine symptoms of depression even after delivery. Scores on the scale range from 0(no symptoms) to a score of 3 (maximum symptom severity). As such, the sum total of the EPDS score must range from 0-30. In this study as has been the case in other studies, depression will be declared in mothers with an EPDS score of ≥12 (Ayers 2013). This will thus help in determining the effect of depression on fear of childbirth.
- Anxiety
Anxiety as a measure will be determined based on its symptoms among the respondents during the 32nd week of pregnancy. The Hopkins Symptom Check List (SCL-25) will be useful in this case. Even so, only the first 10 items of the scale will be utilized. These first 10 mainly focus on indicating the anxiety level in a given respondent. Of the 10 items, each has a score range of 1(“not at all”) to 4 (extremely). The sum of this anxiety score lies between 10 and 40 points. The measure will help in finding the relationship between anxiety and fear of childbirth as it relates to cases of caesarean section.
- Medical Risk Factors
Medical risk factors play an important role in influencing fear of childbirth. This measure will be determined by checking the patient’s ward birth records. The doctor will help in filling this particular section 2 weeks after delivery. Each medical risk factor will be assessed on the merit of whether it is present or not. Among the main risk factors of importance will include; hypertension, kidney disease, rheumatoid arthritis, preeclampsia, epilepsy, heart disease, large foetus and having a non-cephalic presentation (Rosand, Slinning & Eberhard-Gran, et al., 2011). Another crucial factor to be included will be past caesarean section delivery. The factors will be coded in terms of; none existing, 1, 2 or more present. As such, it will be clear how medical risk factors impact on childbirth fear and its link to cases of both elective and emergency caesarean section.
- Overall Previous birth Experience
Ethical Considerations
Measuring an individual’s overall previous birth experience can help determine their fear of childbirth. The researcher will obtain data on each legible participant’s overall previous experience in the initial set of questions in the questionnaires. This can be done at the 17nth week of pregnancy for each participant (Storksen, Garthus-Niegel, & Vangen et al, 2013). A numeric rating scale will be utilized in determining the measure. A response to the question “What can you say was your overall previous birth experience?” The answers will be rated numerically where 0=very good and 10=extremely bad). In this regard, an overall previous birth experience will be termed as negative if it adds up to an NRS score of ≥9 (Nilsson, Bondas & Lundgren, 2010). It is, however, important to note that primiparous women will be classified as those that have never had a previous delivery experience.
At the end of the data collection process, the researcher will check filled-in questionnaires for both completeness and consistency. This will be followed by data cleanup followed which will include editing data, coding, as well as tabulation so as to detect whichever anomalies there might be in the responses. This will as well inform the assignment of particular numerical values to the responses for further analysis. The data will be analyzed using both SPSS and Ms. Excel as the main descriptive statistical tools. The findings will then be presented in forms of tables, graphs, and pie charts so as to facilitate comparison. Quantitative reports will thus be generated in terms of tabulations, percentages, as well as measures of central tendency.
Before the research tools will be finally administered to the legible participants, pre-testing will be carried out in order to make sure that the questions are relevant, quite clearly understandable, as well as sensibly credible. This will determine the validity and/or reliability of these particular research tools.
The researcher will seek necessary authorization from the relevant authorities at the Rosie Hospital. The researcher will also ensure that the respondents adequately understand the research they are taking part in, including its importance to reproductive health research. The authority to pursue this study will be obtained from the Anglia Ruskin University, UK. The information collected will be handled with absolute confidentiality. In order to attain this, the will be expected to remain anonymous through the data collection process, its analysis, interpretation, and report writing. As such, all the respondents will be instructed not to provide their names on the served questionnaires. No respondent will be forced to take part in the study while those that will agree to participate will be encouraged to provide honest responses. Further, the researcher and research assistants will be careful not to mix their own views and thoughts on the findings. This will also call for an acknowledgment of all references and materials used in this particular study.
References
Ayers S. (2013). Fear of childbirth, postnatal post-traumatic stress disorder and midwifery care. Midwifery. 30:145–8. doi: 10.1016/j.midw.2013.12.001.
Fuglenes D, Aas E, Botten G, Øian P, Kristiansen IS.(2013). Maternal preference for cesarean delivery. Do women get what they want? Obstet Gynecol. 120:252–60. doi: 10.1097/AOG.0b013e3182605b1a.
Handelzalts JE, Fisher S, Lurie S, Shalev A, Golan A, Sadan O. (2012). Personality, fear of childbirth and cesarean delivery on demand. Acta Obstet Gynecol Scand. 91:16–21. doi: 10.1111/j.1600-0412.2011.01287.x.
Nilsson C, Bondas T, Lundgren I. (2010). Previous birth experience in women with intense fear of childbirth. J Obstet Gynecol Neonatal Nurs. 39:298–309. doi: 10.1111/j.1552-6909.2010.01139.x.
Rosand GM, Slinning K, Eberhard-Gran M, Roysamb E, Tambs K. (2011). Partner relationship satisfaction and maternal emotional distress in early pregnancy. BMC Public Health. doi: 10.1186/1471-2458-11-161.
Rouhe H, Salmela-Aro K, Gissler M, Halmesmaki E, Saisto T. (2011). Mental health problems common in women with fear of childbirth. BJOG. ;118:1104–11. doi: 10.1111/j.1471-0528.2011.02967.x.
Rubertsson C, Hellstrom J, Cross M, Sydsjo G. (2014). Anxiety in early pregnancy: prevalence and contributing factors. Arch Womens Ment Hlth. 17:221–8. doi: 10.1007/s00737-013-0409-0.
Størksen HT, Garthus-Niegel S, Vangen S, Eberhard-Gran M. (2013). The impact of previous birth experiences on maternal fear of childbirth. Acta Obstet Gynecol Scand. 92:318–24. doi: 10.1111/aogs.12072.
Størksen, H. T., Garthus-Niegel, S., Adams, S. S., Vangen, S., & Eberhard-Gran, M. (2015). Fear of childbirth and elective caesarean section: a population-based study. BMC Pregnancy and Childbirth, 15, 221. https://doi.org/10.1186/s12884-015-0655-4
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